RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02882
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060721

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Cannoneer) medically separated for chronic bilateral anterior knee pain, rated at 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 condition 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 IPEB – Dated 20060509	VA* - (~10 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Anterior Knee Pain	5099-5003	10%	Right Knee Patellofemoral Syndrome 	5299-5261	20%	20070521	
			Left Knee Patellofemoral Syndrome	5299-5261	10%	20070521	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20070713 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The PEB combined the left and right knee conditions under a single service disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (Higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Bilateral Knee Condition.  The service treatment record (STR) documented gradual onset of bilateral knee pain while deployed to Iraq.  Upon redeployment, the physical therapy initial knee evaluation documented sharp, intermittent, 7/10 bilateral knee pain.  Bilateral knee active range-of-motion (ROM) was flexion 135 (140 normal) and extension 0 degrees (0 normal).  A right knee X-ray was normal.  A right knee MRI was normal and showed no evidence of internal derangement.  At an orthopedic surgery evaluation, the CI complained of chronic bilateral knee pain which had not resolved with conservative management.  He complained of bilateral patellofemoral pain with an associated grating sensation.  The CI was able to straighten the knees and denied swelling, locking, buckling, or instability.  The physical exam documented “No tenderness observed on ambulation” and the bilateral knees appeared normal.  There was bilateral tenderness in the patellofemoral regions and retropatellar (behind kneecap) crepitus (grating sound or sensation).  There was no instability or muscle weakness.  There was full ROM with pain with motion.  The assessment listed patellofemoral syndrome ([PFS] symptom complex of anterior knee pain involving the patella).  The weight bearing bilateral knee X-rays were normal.  Podiatry assigned the diagnosis of bilateral patellar chondromalacia (pathologic changes in patellar articular cartilage) based upon history and physical findings.  The MEB narrative summary (NARSUM), 4 months before separation, recounted the history and interventions.  Conservative interventions included activity modification, profiles, physical therapy, knee braces, orthotics, nonsteroidal anti-inflammatory drugs (NSAID's), and oral steroids.  The CI failed to achieve symptomatic relief with conservative management and complained of chronic bilateral 7/10 knee pain.  The physical exam documented a normal gait.  The knee exam revealed bilateral tenderness at the medial, lateral, and superior poles of the patellae.  Valgus/varus stress (assesses medial/lateral collateral ligaments), drawer (assesses anterior and posterior cruciate ligaments), and Lachman's (assesses anterior cruciate ligament) tests were negative and there were 0/5 Waddell’s signs (psychogenic, or nonorganic, manifestations of pain).  The examiner cited the goniometer measured ROM performed by the Brigade Combat Team surgeon.  Knee repetitive active ROM was right flexion 132/132/132, left flexion of 130/130/134, right extension -2/-3/-2, and left extension of -2/-5/-5 degrees.  The diagnosis listed chondromalacia patella.

The VA Compensation and Pension (C&P) exam, 10 months after separation, recounted the history and interventions.  The CI complained of progressively worse bilateral knee pain with associated stiffness, popping, and limited motion.  He denied flare-ups or use of an assistive aid for walking.  The CI reported active treatment with NSAIDs (Ibuprofen) and a poor response to treatments to date.  The physical exam documented an abnormal gait with a mild propulsion deficit.  The bilateral knee exam revealed mild bowing.  There was no tenderness, swelling, effusion (fluid collection), laxity, ankylosis (joint stiffening or immobility), evidence of inflammatory arthritis, objective joint abnormalities, or joint prosthesis.  Knee active ROM was right flexion 129, left flexion of 130, right extension 5, and left extension 0 degree.  There was pain on motion on the left, but not on the right.  There were no changes with repetitions of ROM.  There was no evidence of motor or sensory loss.  Deep tendon reflexes were normal and there were no pathologic reflexes.  The diagnosis listed bilateral patella-femoral syndrome secondary to bowing (mild genu varum).

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The Informal PEB rated the bilateral knee condition at 10% (VA code 5099-5003; rating by analogy-degenerative arthritis).  The PEB cited chronic bilateral anterior knee pain, without specific injury, negative MRI and plain films, no instability, no significant loss of motion, normal exam except for mild patellar tenderness, no surgical options identified, treated conservatively, and rated for slight/constant pain.  The VA rating decision (VARD), citing the C&P exam 10 months after separation, rated the left knee condition at 10% (5299-5261; rating by analogy-leg, limitation of extension of) and the right knee condition at 20% (5299-5261).  For both knee ratings, the VARD cited knee pain, painful flare-ups, mild bowing (genu varum), mild propulsion deficit, ROM, pain on motion, no further limitation of motion on repetitive ROM, no structural abnormalities by imaging studies, no swelling, no effusion, no tenderness, no laxity, no instability, no objective joint abnormality, no evidence of inflammatory arthritis, and treatment with ibuprofen.  The proximate (NARSUM and C&P) exams did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  Members debated if a 10% ratings was warranted for the bilateral knees with application of §4.40 (Functional loss) or §4.59 (Painful motion).  The Board carefully considered the option of rating both knees together, noting that the VA rated each knee separately.  The Board majority concluded that the evidence did not provide sufficient grounds for recommending separate leg disability ratings in this case, and that a bilateral rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral 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 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 and IAW VASRD §4.71a, the Board by a majority vote 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 20140515, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

JUL 1 4 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for, AR20160005129 (PD201402882)

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:
Enclosure
CF:
( ) DoD PDBR
( ) OVA