RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01514
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060809

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Administrative Specialist) medically separated for bilateral knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  The profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic bilateral knee pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (hypothyroidism and migraine headaches) for PEB adjudication.  The Informal PEB adjudicated “bilateral knee pain” as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfit.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Experienced constant pain + discomfort for years that gradually increased over time.  Army determined I was not able to perform as a soldier due to my condition + surgery would not help.  This is a condition I will have for the rest of my life + will only get worse.”  

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 20060630	VA* - (~6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Left Patellofemoral Syndrome	5262-5019	10%	20070223	
			Right Patellofemoral Syndrome	5262-5019	10%	20070223	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 7 	
RATING:  0%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20070625 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Bilateral Knee Pain Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s bilateral knee pain condition began in 2000 with pain and swelling after a prolonged running episode.  Repeated exacerbations of swelling, pain, and buckling after running or activity did not abate despite conservative therapy.  In December 2005 radiographic studies (MRIs) showed possible meniscal tears in the left and right knees.  Surgery appeared to be one potential option for treatment and the CI elected to continue with MEB.  The MEB NARSUM dated 10 April 2006, 3 months prior to separation, noted that the CI reported bilateral knee pain, swelling, locking, and knees giving out despite use of a sleeve/brace.  The MEB physical exam noted bilateral knee tenderness without instability.  The CI was “able to heel and toe walk but unable to squat and duck walk secondary to knee pain.  The remainder of her physical exam was normal.”  The examiner referenced the orthopedic and physical therapy (PT) evaluations charted below.  

At the VA Compensation and Pension (C&P) examination on 23 February 2007, performed 6 months after separation, the CI reported bilateral anterior knee pain with right greater than left flares to severe 2-3 times per month including knee swelling and buckling and limited flexion.  The CI used bilateral knee braces at times and had little benefit from Tylenol.  Walking was not limited.  Exam documented a normal gait with no knee instability and is otherwise summarized below.  Remote VA rating indicated the CI had right knee meniscal surgery in 2007 and the VA increased each knee rating to 20% effective July 2013 citing meniscal symptoms of frequent episodes of “locking,” pain, and effusion into the joint for both knees.  The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Knee ROM
(Degrees)	Ortho ~4 Mos. Pre-Sep	PT/MEB ~3 Mos. Pre-Sep	VA C&P ~6 Mos. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	“B/L Full AROM”	126, 127, 127	125, 126, 125	125	125	
Extension (0 Normal)		0, 0, 0	0, 0, 0	0	0	
Comment	Pain on motion; crepitus; + compression test	Pain w/ AROM extension	With pain; normal motor and reflex exams	
§4.71a Rating	10%	10%	10%	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the combined bilateral knee condition 0% coded analogously to 5003, (degenerative arthritis), citing application of the USAPDA pain policy.  The VA rated each knee separately at 10% coded 5262-5019 (tibia and fibula impairment-bursitis; which uses 5003 rating criteria) citing painful and limited motion.  Later VA rating was adjudged post-separation worsening and not indicative of the CI’s disability picture at the time of separation.  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, each joint must be reasonably justified as unfitting for separate disability ratings.  In this case, almost every clinical entry was for complaints and pathology for both knees; both knees were considered to fail retention standards; both were implicated by the NARSUM; and, both were profiled.  The commander’s statement was silent.  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.  

All exams documented painful (or pain-limited) motion of each knee which would warrant a 10% rating IAW VSRD §4.59 (painful motion).  Alternative coding under 5259 (semilunar cartilage – meniscus symptomatic) would be no higher than 10% for each knee and includes painful motion.  There was not sufficient evidence for higher rating under limited ROM knee codes and insufficient evidence of frequent episodes of “locking,” pain, and effusion into the joint for higher rating for either knee under 5258 (semilunar cartilage – meniscus dislocated).  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 left knee and 10% for the right knee condition.  

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 (AR 635-40) for rating the 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 recommends that each joint be separately adjudicated as follows:  an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 and rated 10%, both 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	
Bilateral Knee Pain	Left	5099-5003	10%	
	Right	5099-5003	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, undated, w/atchs
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, AR20160003133 (PD201401514)

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