RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01226
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Information Technology Specialist, medically separated for “bilateral chondromalacia patella,” with a disability rating of 20%.  

CI CONTENTION:  The CI makes no specific contention in his application.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON: 

SERVICE PEB - 20090521	VARD - 20091202 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Chondromalacia Patella	5099-5003	20%	Patellofemoral Syndrome Right Knee	5099-5019	10%	20090828	
			Patellofemoral Syndrome Left Knee	5099-5019	10%	20090829	
RATING:  20%	RATING:  40%	

ANALYSIS SUMMARY:  

Bilateral Knee.  According to Service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), right knee symptoms began approximately 7 years prior to referral for MEB.  The CI was diagnosed with symptomatic right medial patellar plica (synovial membrane fold) and was given a steroid injection with no significant improvement.  The CI underwent an arthroscopic right medial patellar plica resection which revealed patellar chondromalacia (abnormal cartilage softening or degeneration).  Following convalescence he reported no improvement, and possible worsening, of pain.  Two years post-operatively, diagnostic imaging (magnetic resonance imaging [MRI]) of the bilateral knees were normal.  The CI complained of worsening of his chronic right knee problems with associated buckling and giving out.  While deployed to Iraq, he was diagnosed with prepatellar tendonitis (acute tendon inflammation or irritation).  Left knee symptoms were reported to worsen because of compensation for right knee symptoms.  Right knee diagnostic imaging (X-ray) showed possible lateral knee joint soft tissue swelling.  A recommended MRI showed tendinopathy (chronic localized tendon thickening) at the insertion of the quadriceps tendon on the patella and subtle degenerative changes in the posterior horn of the medial meniscus.  At an evaluation for the MEB, the CI reported his knees worsened over time while deployed to Iraq. Symptoms were exacerbated by prolonged sitting, prolonged walking, running, and stairs.  The physical examination documented a normal gait with no tenderness observed on ambulation.  The bilateral knee examination revealed no tenderness, effusion (fluid collection), erythema (redness), or misalignment.  The anterior/posterior drawer (assess anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]), Lachman (assess ACL), McMurray (assess menisci), patellar apprehension (apprehension or pain on quadriceps contraction with patella displaced) tests were negative.  There was normal motion with crepitus (grating sensation or sound) on motion.  Pain was elicited with right, but not left, knee motion.  Active range of motion (ROM) was measured with a goniometer.  Right knee flexion was 120 (140 normal) and extension was 0 (0) degrees.  Left knee flexion was 135 (140) and extension was 0 (0) degrees.  Strength was normal.  The assessment listed internal derangement of knee.  

The 28 April 2009 NARSUM, 3 months before separation, recounted the history and interventions.  Post-operatively, the CI did not improve with conservative management (activity modification, physical therapy, braces, and medications) and was not deemed a surgical candidate.  He complained of chronic 1/10 right knee pain and intermittent left knee pain.  The right knee could buckle stepping off a curb and pain could increase to 8/10 with activity.  Symptoms were exacerbated by prolonged sitting, prolonged walking, running, load bearing, and stairs and relieved with rest, stretching, ice, and Motrin.  The physical examination documented a normal gait with no tenderness observed on ambulation.  The right knee examination revealed well-healed surgical scars.  The bilateral knee examination revealed diffuse anteromedial and anterolateral tenderness.  There was poor patellar tracking and crepitus with no instability, weakness, or other internal derangements.  Strength, sensation, and deep tendon reflexes (DTRs) were normal but there was pain with strength and DTR testing.  The diagnosis listed chronic bilateral knee pain due to patellar chondromalacia.  

The 29 August 2009 compensation and pension (C&P) examination, a month after separation, recounted the history and interventions.  The CI complained of progressively worsening bilateral knee pain with associated tenderness, swelling, stiffness, limited motion, locking (2-3 times a week), and giving way.  Symptoms were exacerbated by prolonged walking, running, lifting, carrying, and stairs.  He denied a history of trauma, neoplasm, muscle symptoms, flare-ups, weakness, paralysis, paresthesia (abnormal sensation, tingling, burning, prickling), or numbness.  The active medication was Ibuprofen.  The physical examination documented a normal gait.  The bilateral knee examination revealed anterior joint line tenderness with no effusion, swelling, atrophy, spasm, ankylosis (joint stiffening or immobility), laxity, or evidence of inflammatory arthritis.  The McMurray tests were negative.  Bilateral knee active ROM was flexion of 120 and extension of 0 degrees.  There was pain with ROM, but no loss of function with repetitive ROM.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  Bilateral knee X-rays were normal.  The CI was employed fulltime and had lost no time from work in the past 12 months.  The diagnosis listed bilateral patellofemoral syndrome ([PFS] anterior knee pain symptom complex involving patella).  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 20% (10% each knee) rating under an analogous 5003 code (degenerative arthritis) citing bilateral chondromalacia patellar, pain, ROM, and rated for limitation of motion of one major joint for each knee.  The VA assigned a 10% rating for the right knee, and a 10% rating for the left knee, under an analogous 5019 code (bursitis) based on the C&P examination a month after separation.  For the bilateral knees, the VA cited PFS, patellar chondromalacia, right knee medial plica excision without symptom improvement, X-ray and MRI findings, pain, swelling, locking, giving way, symptoms exacerbated by activity, right knee healed surgical scars, tenderness, crepitus, poor patellar tracking, negative McMurray, ROM, pain with ROM, and no additional loss of function due to pain, fatigue, weakness, instability, or incoordination.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The Board considered the option of rating both knees together, noting that while the PEB and VA assigned individual 10% knee ratings, overall the PEB and VA rated the knees as a bilateral condition.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate knee disability ratings in this case, and that a bilateral rating of 20%, coded 5099-5003, supported the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160010633 (PD201401226)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (DoD PDBR) recommendation and record of proceedings pertaining to the
subject individual. Under the authority of Title 10, United States Code, section 1554a,
I accept the Board's recommendation and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA