RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01511
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistical Specialist, medically separated for “bilateral patellar-femoral pain syndrome,” with a disability rating of 0%.

CI CONTENTION:  The CI was given a higher rating by the Veterans Administration.  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 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:  

SERVICE PEB - 20070807	VARD - 20080620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellar-femoral Pain 	5099-5003	0%	Bilateral Patellofemoral Syndrome	5024	0%	STR	
Flat Foot, Bilateral	Not Unfitting 	Bilateral Pes Planus	5276	0%		
Legally Blind, Left Eye	Not Unfitting	No VA Placement	
Toxocariasis, Left Eye	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Knee.  According to service treatment records and the medical Evaluation Board (MEB) narrative summary (NARSUM) dated 28 June 2007, the right knee condition began approximately January 2005, when the CI was carrying a heavy load up a steep hill as part of a road march.  Evaluation in the primary care clinic on 2 March 2005 concluded with a diagnosis of joint pain, localized in the knee.  Evaluation in the primary care clinic on 18 April 2005 concluded with a diagnosis of patellofemoral syndrome.  X-ray studies on 29 August 2005 showed no evidence of fracture, dislocation or other abnormality.  There was no effusion or significant arthritic change.  The joint space was adequately maintained.  Magnetic resonance imaging (MRI) on 1 December 2005, showed a normal knee without evidence of derangement.  Duty limitations were recommended by Physical Profile (DA Form 3349) dated 7 May 2007, that included no physical loading impact activities, no jogging, running, jumping, marching or heavy lifting or carrying greater than 15 pounds.  According to the commander’s statement dated 6 June 2007, the CI was not able to perform her assigned duties of her Army specialty and could not take the physical fitness test.  The CI was treated with duty limitations, medications, and physical therapy (PT) with no significant benefit.  The CI experienced persistent duty limiting symptoms including swelling of her knees with any bending and pain, and was referred for MEB.  

At the MEB examination on 28 June 2007, the CI reported daily knee pain causing occasional falls.  The pain occurred during sleep as well.  She experienced daily locking and some numbness following episodes of instability that lasted 3-5 minutes.  She noted grinding, popping, and swelling bilaterally.  Pain was focused on the kneecaps and alternated between sharp and dull.  The pain was rated 6/10 pain scale at best and 10/10 at its worst.  The pain was aggravated by running, walking, climbing stairs, or lifting.  The pain was relieved by medication (Motrin and Roxicet).  The MEB physical examination noted tenderness to palpation over bilateral patellofemoral areas, with crepitus with knee range of motion (ROM).  There was a minimally abnormal gait that favored the bilateral lower extremities.  There was tenderness with knee flexion and extension with crepitus bilaterally.  There was no effusion, erythema, warmth, or knee deformity.  There was no popliteal cyst or patellar shift.  Examination tests for ligamentous instability and meniscus pathology were negative.  ROM testing (using goniometer) was done on 28 June 2007, and showed flexion of 134 degrees, limited by pain.  Extension was 0 degrees, with no pain.  The VA used the service treatment records (STR) to determine their rating decision.  

There was no VA Compensation and Pension (C&P) examination in evidence, proximate to separation. 

The Board directed attention to its rating recommendation based on the evidence.  The PEB combined the right knee and left knee conditions as a single unfitting condition coded 5099-5003 and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.   The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD code 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right knee and left knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board members concluded that the preponderance of evidence showed that the right knee condition would reasonably have caused the CI to be referred into the DES, or be found unfit due to the right knee condition.
As noted above, the PEB bundled the right knee with the left knee condition and applied a 0% rating (coded 5099-5003).  The VA rated the bilateral patellofemoral syndrome 0% (coded 5024), citing that there was no medical evidence to show the CI met the criteria for a compensable evaluation, and that the CI did not report for the scheduled VA C&P examination.  After due deliberation, considering all of the evidence the Board recommends a separately unfit determination with a disability rating of 10% for the right knee condition.  

Left Knee.  According to service treatment records and the MEB narrative summary (NARSUM) 28 June 2007, the left knee condition began approximately January 2005, 2 years prior to referral for an MEB when the CI was carrying a heavy load up a steep hill, while on a ruck march.  Evaluation in the Primary Care clinic on 2 March 2005 concluded with a diagnosis of joint pain, localized in the knee.  Evaluation in the Primary Care clinic on 18 April 2005 concluded with a diagnosis of patellofemoral syndrome.  X-ray studies on 29 August 2005 showed no evidence of fracture, dislocation or other abnormality.  There was no effusion or significant arthritic change.  The joint space was adequately maintained.  Magnetic resonance imaging (MRI) on 1 December 2005 showed a normal knee without evidence of derangement.  Duty limitations were recommended by Physical Profile (DA Form 3349) dated 7 May 2007, including no physical loading impact activities to include jogging, running, jumping, marching or heavy lifting or carrying greater than 15 pounds.  According to the commander’s statement dated 6 June 2007, the CI was not able to perform her assigned duties of her Army specialty and could not take the physical fitness test.  The CI was treated with medication, rest, and physical therapy with no benefit.  The CI experienced persistent duty limiting symptoms including swelling of her knees with any bending and pain, and was referred for MEB.  
      
The Board first considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board members concluded that the preponderance of evidence showed that the left knee condition would reasonably have caused the CI to be referred into the DES or be found unfit due to the left knee condition.

At the MEB examination, on 28 June 2007, the CI reported daily knee pain causing occasional falls.  The pain occurred during sleep as well.  She experienced daily locking and some numbness following episodes of instability that lasted 3-5 minutes.  She noted grinding, popping, and swelling bilaterally.  The pain was focused on the kneecaps and alternated between sharp and dull.  The pain was rated 6/10 pain scale at best and 10/10 at its worst.  The pain was aggravated by running, walking, climbing stairs, or lifting.  The pain was relieved by medication (Motrin and Roxicet).  The MEB physical examination noted tenderness to palpation over bilateral patellofemoral areas, with crepitus with knee range of motion (ROM).  There was a minimally abnormal gait that favored the bilateral lower extremities.   There was tenderness with knee flexion and extension with crepitus bilaterally.  There was no effusion, erythema, warmth, or knee deformity.  There was no popliteal cyst or patellar shift.  Examination tests for ligamentous instability and meniscus pathology were negative.  ROM testing (using goniometer) on 28 June 2007 showed flexion of 132 degrees, limited by pain.  Extension was 0 degrees with no pain.  

The Board directed attention to its rating recommendation based on the evidence.  The PEB bundled the right knee with the left knee condition and applied a 0% rating (coded 5099-5003).  The VA rated the bilateral patellofemoral syndrome 0% (coded 5024) citing that there was no medical evidence to show the CI met the criteria for a compensable evaluation, and that the CI did not report for the scheduled VA C&P examination.  After due deliberation, considering all of the evidence the Board recommends a separately unfit determination with a disability rating of 10% for the left knee condition.  

Other PEB Conditions.  Three conditions were adjudicated by the PEB as “Not unfitting.”  These three conditions were: Flat foot (bilateral), legally blind left eye, and toxocariasis left eye.  The Board’s main charge with respect to these conditions is to assess the appropriateness of the PEB’s adjudication.  The Board’s threshold for countering a fitness determination is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. These three conditions were thoroughly reviewed by the Board.  It was determined that none of these conditions were judged to fail retention standards, nor were they specifically profiled.  The Board found insufficient evidence in the record that any of these three conditions significantly interfered with satisfactory performance of military duties.  After due deliberation, and in consideration of the preponderance of the evidence, the Board found insufficient cause to recommend a change in the PEB adjudication of these conditions.  

BOARD FINDINGS:  In the matter of the bilateral patellar-femoral pain syndrome, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition, coded 5299-5260 and rated 10%, and an unfitting left knee condition, coded 5299-5260 and rated 10%, both IAW VASRD §4.71a.  In the matter of the three other PEB conditions (Bilateral flat feet, legally blind left eye, and Toxocariasis left eye), the Board unanimously recommends no change in the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, 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	
Patellar-femoral pain syndrome, right knee 	5299-5260	10%	
Patellar-femoral pain syndrome, left knee	5299-5260	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140328, 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 XXXXXXXXXXXXXXXXXXXXX, AR2016001 0358 (PD201401511)

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