RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02288
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041012

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

CI CONTENTION: The CI contends for his unfitting bilateral knee condition and a number of conditions not identified by either the Medical Evaluation Board or Physical Evaluation Board.  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 - 20040608	VARD - 20061011	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain due to Retropatellar Pain Syndrome	5099-5003	0%	Right Knee Strain	5257	0%	20060713	
			Left Knee Strain	5257	0%	20060713	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY: 

Chronic Bilateral Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in June 2002 after running.  An X-ray of the right knee in September 2003 was normal, with an X-ray of the left knee in March 2004 also normal.  Despite treatment, the bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “retropatellar pain syndrome” for PEB adjudication.
At the MEB examination (recorded on DD Forms 2807 and 2808) dated April 2004, 6 months prior to separation, the CI reported chronic knee pain in both knees and stated he had completed a 20 kilometer road march approximately 1 year prior.  Physical examination indicated that based on the negative X-rays, an MRI was not indicated.

The NARSUM, also written in April 2004, indicated the CI reported bilateral knee pain with morning stiffness.  Pain was worse with prolonged sitting, walking, standing and became “excruciating with running.”  Pain was worst when getting up from a sitting position.  The examiner indicated the CI had difficulty with any exertional aerobic activity.  Physical examination noted painful range of motion (ROM) for the right knee flexion and patellar compression, bilateral knee extension was pain free, normal gait, no evidence of ligamentous laxity and a negative McMurray’s test (for meniscal pathology).  The CI was diagnosed with retropatellar pain syndrome.  ROMs are charted below.

At the VA Compensation and Pension (C&P) examination in July 2006, performed 20 months after separation, the CI reported intermittent morning aching pains with stiffness in both knees with no history of weakness, swelling, instability, or locking of the knees.  Physical examination showed a steady gait, bilateral painful motion on extension, no tenderness, edema, effusion, instability, weakness, or guarding movement.  X-rays showed no significant bone or joint abnormality, and the diagnosis was bilateral chronic myoligamentous strain.  

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are as follows:

Knee ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	VA C&P ~20 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	125	140	110	75	
Extension (0 Normal)	0	0	0	0	
Comment	No Painful motion	Painful motion	Painful motion; no laxity or instability	
§4.71a Rating	0%-10%	10% (PEB 0%)	10% (VA 0%)	10% (VA 0%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5003 code (arthritis, degenerative), citing the U.S. Army Physical Disability Agency Pain Policy.  The VA assigned a 0% rating for both the left and right knees, using the 5257 code (knee, other impairment of, recurrent subluxation or lateral instability) based on the VA C&P examination 20 months after separation, citing “a noncompensable evaluation is assigned unless there is recurrent subluxation or lateral instability of the knee which is slight” for both knees.  The VARD narratives for the knee did not mention the examination finding of “positive painful motion on extension, both knees.”

The NARSUM examination had normal right knee ROM with painful motion.  The left knee had limited flexion and was adjudged to have sufficient evidence of functional loss based on the diagnosis and history of pain on motion.  The remote VA examination had clear evidence of painful motion for each knee.  A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the MEB and VA exams provided satisfactory evidence for painful motion of each knee; thus, separate joint ratings are indicated IAW §4.71a.

The Board adjudged that there was sufficient evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).

The Board considered coding analogously to code 5021 (myositis) which defaults to 5003 (degenerative arthritis) rating criteria, without regard to radiographic findings, or to 5261 (leg, limitation of extension) as suggested for patellofemoral syndrome/retropatellar under the table of analogous codes in effect at the time.  There was no difference in rating and the code choice of 5099-5003 was acceptable.  After due deliberation, an in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that each knee be separately unfitting with a disability rating of 10% for the left knee pain and 10% for the right knee pain; each coded 5099-5003.

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

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain	5099-5003	10%	
Right Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, 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 XXXXXXXXXX, AR20160007489 (PD201402288)

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