RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-02537
BRANCH OF SERVICE:  Army                                                                    SEPARATION DATE:  20030513

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Psychological Operations Specialist, medically separated for “bilateral knee pain…,” with a disability rating of 10%.  

CI CONTENTION:  At the time of his separation there was limited information regarding traumatic brain injury.  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 based upon a 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 - 20030212	VARD - 20030724	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Retro Patella Pain Syndrome, Right	5299-5257	0%	STR	
			Retro Patella Pain Syndrome, Left	5299-5257	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 14 January 2003 indicated the CI had several short-term profiles for knee pain after running and rucking on and off for approximately 6 years.  In December 1997 he had a bad parachute landing fall in which he injured his right knee that did recover.  His left knee began to be a chronic problem in 1999.  The CI sustained a hard parachute fall in February 2001 when he landed on his feet.  The CI still complained of left knee pain in June 2001 despite undergoing physical therapy.  X-rays of the left knee were normal on 27 June 2001; magnetic resonance imaging (MRI) showed a minimal signal abnormality likely related to degenerative change and was otherwise unremarkable with no meniscal tear identified; and a bone scan revealed a possible left anterior tibial tubercle stress reaction.  The CI’s condition was assessed as retropatellar pain syndrome/stress reaction, and over time, he achieved the maximal benefit of physical therapy and anti-inflammatory medication, but pain persisted.  On examination he had a WFL [within functional limits] range of motion (ROM) and 5/5 strength with continued pain at the inferior and anterior thigh and superior tibia.  In March 2002 the CI had tenderness to palpation at the greater trochanter and a positive patellar grind.  In June 2002 he complained bilateral knee pain, which was present since 1997.  Bilateral knee pain continued through October 2002 and the CI walked with a limp.  At an orthopedic evaluation on 17 October 2002 the CI complained of bilateral knee pain (left worse) with sitting, standing, walking, sleeping, and climbing stairs.  He had occasional popping without swelling or locking.  No improvement occurred with conservative treatment and temporary profiles for greater than a year.  At the NARSUM examination the CI had difficulty arising from a squatting position without using his arms secondary to knee pain.  Orthopedic examination showed there was a full ROM and no effusion in either the right or left knee.  The left knee had minimal tenderness to palpation with patellar compression and a ligamentously stable knee with no joint line tenderness.  The right knee revealed tenderness to palpation at the tibial tubercle with patellar compression.  The knees were stable with no joint line tenderness, no varus or valgus laxity, and the Q angles (angle of alignment to the knee) were normal bilaterally.  The orthopedic surgeon’s impression was anterior knee pain, unresponsive to conservative therapy, while the NARSUM examiner reported the CI noted his knee pain was worse in the prior year, especially the left, which gave him constant problems; and pain was increased with vigorous activity or twisting action.  However, the CI was not overly concerned with his right knee and he took no medications.

A permanent L3 profile was approved on 1 November 2002 for bilateral knee pain with limitations of no 2 mile run and road marching at his own pace.  At the MEB examination dated 19 November 2002, the CI reported on DD Form 2807-1 Report of Medical History bilateral knee pain.  The MEB physical examiner noted on DD Form 2808 the CI was unable to arise from a squat position without use of his arms secondary to knee pain.  The commander’s statement dated 30 January 2003 indicated the CI’s medical problems started in late 1997 when he injured both knees numerous times from road marching, jumping, and running.  Over time his condition worsened from running on soft sand and rough terrain and he continued to suffer from bilateral knee pain with the left knee in constant pain.  As a result the CI had a difficult time running and could not road march due to the severe pain to his knees.

No VA Compensation and Pension (C&P) examination was available for review.  The VA Rating Decision dated 25 July 2003 was based on STRs.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5003 (degenerative arthritis) for bilateral knee pain with the left being worse than the right.  The PEB assigned a 0% rating using code 5299-5257 (knee, other impairment-recurrent subluxation or lateral instability) for retropatellar pain syndrome, right knee and a 0% rating using code 5299-5257 for retropatellar pain syndrome.  

Board Approach to PEB Consolidated Rating. The PEB combined the bilateral knee pain conditions as a single unfitting condition coded 5099-5003 and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40). The approach by the PEB commonly 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’s initial charge in this case was 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 Disability Evaluation System or be found unfit because of physical disability.  The evidence for the bilateral knee pain conditions was presented together above.  Members agreed that each knee condition is separately unfitting, although the left knee was worse, and a rating for each knee is applicable.  Both knees had a full ROM; painful motion was not recorded; and there was no evidence of laxity or recurrent subluxation.  In the absence of ankylosis, meniscal dislocation or removal, or tibia and fibula impairment, neither knee independently warranted a rating higher than 0%.  However, when the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB, which assigned a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140508, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

XXXXXXXXXXXXX

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXX, AR20160011117 (PD201402537)

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, I accept
the Board's recommendation and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:
Enciosure
CF:
( ) DoD PDBR
( ) OVA