RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE: PD-2014-01434 
BRANCH OF SERVICE:  Army	SEPARATION DATE: 20040505  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Medical Specialist) medically separated for bilateral knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “bilateral retropatellar femoral pain syndrome” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic bilateral knee pain” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in her application.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the 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/Naval 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 confined to 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:  

IPEB – Dated 20040309	VA* - Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Retropatellar Femoral Pain Syndrome, Left Knee	5022	10%	STR	
			Retropatellar Femoral Pain Syndrome, Right Knee	5022	10%		
Other x 0 (Not In Scope)	Other x 4 	
RATING:  10%	COMBINED RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20041221 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  The PEB combined the right and left retropatellar knee conditions as a single unfitting condition coded analogously as 5099-5003 and rated 10% with application of the USAPDA pain policy.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  The evidence for both knees is presented, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Chronic Bilateral Knee Pain.  The service treatment record (STR) included an MEB DD Form 2807-1, Report of Medical History (entrance examination dated 12 February 2003) on which the examiner documented “difficulty rising from a kneeling position” without further comment or evaluation other than annotating that the lower extremities were "normal."  An acute care visit in August 2003 (3 months after entry) documented right knee pain after marching.  A bone scan in September 2003 (8 months pre-separation) for bilateral lower extremity pain documented “mild left knee uptake consistent with stress change.”  There was no comment regarding the right knee.  Radiographs in January 2004 (4 months pre-separation) documented normal bilateral knee alignment without fracture, bone or cartilage defects, or sclerosis (thickening or hardening of the tissues as a result of repeated stress).  The commander’s statement, (January 2004), stated that the bilateral knee pain prevented her from “lifting, doing pushups, and from performing critical field duties such as carrying patients and medical equipment.”  

The MEB Narrative Summary (NARSUM) exam was performed on 14 January 2004; 4 months pre-separation.  The CI reported left knee pain that began during basic training with subsequent development of right knee pain.  The bilateral knee pain was rated as a 3-4/10 and did not improve with a patellar stabilizing brace (on the left).  Pain occurred with running, standing for prolonged periods of time, and with jumping activities.  She denied any direct injury or trauma to the knees.  The examiner documented a “slightly unassisted antalgic gait,” normal strength, and a bilateral range-of-motion from negative 5 to 140 degrees (normal 0-140).  There was evidence of knee pathology: patellar grind bilaterally; mild lateral movement of the patella (“J sign”) with knee extension; normal mobility, and a “decrease” [abnormal] tilt of the patella.  There was no evidence of effusion, edema or joint line tenderness.  There was no laxity with varus and valgus stress and negative meniscal testing.  On the MEB DD Form 2807-1 Report of Medical History (dated 21 January 2004), the CI reported that the knee gave out “occasionally,” and that she wore a brace “to keep knee cap stable.”  There was no STR evidence of locking or effusion; recurrent subluxation or lateral instability; flexion limited to 30 degrees; or extension limited to 15 degrees.  

There was no VA Compensation and Pension (C&P) exam performed after separation until June 2006 (2 years after separation).  However the VA Rating Decision (VARD) dated 21 December 2004 documented findings reviewed in the STR and used to arrive at their rating.  A VA Compensation and pension (C&P) exam was performed on 12 June 2006, 2 years after separation.  The CI reported pain localized behind the knees that occurred 5 times per week, lasting 2 hours each.  The pain was aggravated by physical activity, relieved by rest and medications, with no functional impairment or incapacitation.  The examiner documented tenderness on exam of the bilateral knees with no edema, effusion, abnormal movement or guarding of movement of either knee.  There was flexion to 140 degrees of both knees.  All testing of the ligamentous and meniscal structures of both knees was within normal limits.  Radiographs documented normal bilateral knees.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB combined bilateral retropatellar femoral pain syndrome under a single unfitting condition, and rated 10% in accordance with the USAPDA pain policy, analogously coded 5099-5003 (degenerative arthritis).  The VA coded both knees separately as 5022 (periostitis), and rated 10% for the right knee and 10% for the left knee conditions.  

The Board first considered if the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  Members agreed that the evidence of the record reasonably supported that each knee was separately unfitting; and, that coding and rating features were essentially identical.  

A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the NARSUM provided satisfactory evidence for patellar dysfunction (periostitis or chondromalacia) and painful motion supportive of separate joint ratings IAW §4.71a.  The VA C&P exam established the chronicity of the bilateral condition 2 years post-separation.  There was no evidence of recurrent subluxation or lateral instability of a moderate degree that would support a higher rating under applicable VASRD coding.  There was no documentation of flexion limited to 30 degrees, extension limited to 15 degrees, locking or effusion, or ankylosis to support a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee and 10% for the left knee condition, analogously coded 5099-5022 (periostitis).  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the USAPDA pain policy for rating bilateral knee condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the bilateral knee condition, the Board unanimously agrees that both knees were separately unfitting and unanimously recommends a disability rating of 10% for the right knee and 10% for the left knee, coded 5022 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Retropatellar Femoral Pain Syndrome	5099-5022	10%	
Left Retropatellar Femoral Pain Syndrome	5099-5022	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131113, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

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 XXXXXXXXXXXXXXXXXX, AR20160003114 (PD201401434)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA