RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-02474
BRANCH OF SERVICE:  Army	Separation Date:  20070811

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Metal Worker) medically separated for chronic bilateral knee pain.  The bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Bilateral patellar chondromalacia” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic bilateral knee pain secondary to chondromalacia…” as unfitting, rated 0%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his knees by the VA and believes the Service rating should be higher.  He was also not evaluated for PTSD and tinnitus. His complete submission is at Exhibit A.  

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 20070712	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain Secondary to Chondromalacia	5099-5003	0%	Chondromalacia Patella, Right Knee	5010-5257	10%	20071017	
			Chondromalacia Patella, Left Knee	5010-5257	10%	20071017	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3 	
RATING:  0%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20071127 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  The PEB rated the chronic bilateral knee pain (secondary to chondromalacia) condition under the single analogous code 5099-5003 (arthritis, degenerative).  This coding approach was countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation.  If compensable ratings for each joint are achieved IAW VASRD §4.71a, the Board must apply separate codes and ratings in its recommendations.  If the Board judges that two or more separate ratings are warranted, it must satisfy the requirement that each “unbundled” condition is reasonably justified as unfitting, with the caveat that the final recommendation may not produce a lower combined rating than that of the PEB.  

Chronic Bilateral Knee Pain Secondary to Chondromalacia Condition.  The CI developed bilateral knee pain and popping in September 2006.  A bilateral knee X-ray done in January 2007 was normal.  A left knee MRI done in February 2007 showed advanced patellar chondromalacia and a small joint effusion.  A right knee MRI showed advanced patellar chondromalacia, a surface ulceration, a small joint effusion and some fluid in the gastrocnemius bursa.  Despite extensive physical therapy (PT), orthopedic evaluations and medications, the bilateral knee pain continued to interfere with duty performance.  The MEB Narrative Summary (NARSUM) exam, approximately 3 months prior to separation, documented that the CI reported significant bilateral knee pain that severely limited his activity.  The MEB NARSUM physical exam findings are summarized in the chart below.  The VA Compensation and Pension (C&P) exam approximately 2 months after separation documented functional limitations of an inability to stand for greater than 15 to 30 minutes and an inability to walk more than 1/4-mile but less than 1 mile.  The CI reported bilateral knee pain.  

There were goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.  

Knee ROM
(Degrees)	MEB ~3 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	95, 95, 100	90, 95, 90	0-120	0-110	
Extension (0 Normal)	5, 5, 5	5, 5, 5	0	0	
Comment	Limited by painful motion	Grinding; tenderness; sub patellar tenderness; antalgic gait	
  §4.71a Rating	10%	10%	10%	10%	
The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB adjudicated the chronic bilateral knee pain as unfitting.  The VA rated each knee separately at 10%; coded 5010 (arthritis, due to trauma, substantiated by X-ray findings) with 5257 (knee, other impairment of).  The Board first considered if the each knee having been uncoupled from the combined rating could be reasonably justified as independently unfitting.  The Board noted that multiple treatment notes evidenced reports of pain in both knees which was well documented throughout the service treatment record and notes rarely pain isolated to a single knee joint.  Both knees were profiled and the commander’s statement indicated “knee problems” interfered with performance of MOS duties.  There were no unilateral distinctions with regards to clinical features or fitness considerations.  Members agreed that the each knee independently would have rendered the CI incapable of continued service within his training for his MOS and that each knee is separately unfitting.  Identical coding and ratings are applicable.  
The Board noted that examinations most proximate to separation documented pain-limited knee motion or limited motion with grinding, and the PEB disability description noted ROM decreased by pain.  The Board determined that there was satisfactory evidence of pain-limited motion for a 10% rating for each knee under the criteria of 5003 (or with application of VASRD §4.59 [painful motion]).  There was no evidence of incapacitating exacerbations, instability, current meniscal injury, or more limited ROMs for the knee joint that would have resulted in a rating higher than 10% for either knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.59, the Board recommends that each knee be found to be unfitting with a disability rating of 10% for each knee; each coded 5099-5003 IAW VASRD §4.71a.  

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 AR 635-40 for rating the bilateral knee pain was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the chronic bilateral knee pain, the Board unanimously determined that each knee was separately unfitting and recommends a 10% rating for each knee for a combined rating of 20%, coded 5099-5003 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 his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Bilateral Knee Pain Secondary to Chondromalacia  	Right	5099-5003	10%	
	Left	5099-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160004554 (PD201402474)

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