RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03001
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E5, Ammunition Specialist, medically separated for “chronic bilateral knee pain” with a disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.” 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 - 20040115	VARD - 20040915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5003	20%	Degenerative Arthritis Right Knee	5010	10%	20040803	
			Degenerative Arthritis Left Knee	5010	10%	20040803	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary, the CI had knee pain since basic training in 1983.  A note in June 2001 indicated the CI was unable to run due to advanced arthritis of the right knee.  She felt her condition had worsened and she had difficulty with standing as well as with walking or sitting for long periods of time.  Range of motion (ROM) measurements from a physical therapy examination in October 2003 are documented in the chart below.  X-rays of the knees in November 2003 demonstrated moderate degenerative changes.  Bilateral knee steroid injections were administered on 18 November 2003.  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 “bilateral knee pain” for PEB adjudication.

At the MEB examination (recorded on the DD Forms 2807 and 2808) dated November 2003, 4 months prior to separation, the CI reported arthritis and painful knee problems.  The medical examiner noted mild crepitation of the knees bilaterally and slightly decreased ROM of the knees.  
The NARSUM examiner, on 19 December 2003, noted right knee tenderness along the medial aspect of the joint line and left knee tenderness with patella compression testing but no obvious swelling or effusion of either knee.  Laxity testing of the right knee was difficult to perform due to pain, but there was no valgus or varus instability and no evidence of a meniscal tear in the left knee. The CI had an abnormal gait and was unable to flex her right knee beyond 60 degrees, which caused the gait to be shortened.  

At the VA Compensation and Pension (C&P) examination dated 3 August 2004, performed 4 months after separation, the CI reported swelling, pain and stiffness, but that she had no incapacitation.    ROM measurements were limited by pain and are documented in the chart below.  The examiner noted locking pain and crepitus in both knees but no laxity or evidence of a meniscal tear.  Knee X-rays in August 2004 demonstrated minimal degenerative changes bilaterally and marked narrowing of the patella-femoral joint spaces, while X-rays in November 2004 revealed moderate tri-compartmental bilateral knee osteoarthritis.  

The 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)	PT/MEB ~5 Mos. Pre-Sep
	VA C&P ~4 Mos. Post-Sep
	
	Left	Right	Left	Right	
Flexion (140 Normal)	90	60	100	100	
Extension (0 Normal)	5	10	0	0	
Comment	Pain on laxity testing	Limited by pain, locking pain and crepitus	
§4.71a Rating	PEB 20%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5003 (degenerative arthritis) for chronic bilateral knee pain with degenerative arthritis changes citing the Army pain policy.  The VA assigned a 10% rating using code 5010 (arthritis, due to trauma, substantiated by X-ray findings) for degenerative arthritis of the right knee and a 10% rating using code 5010 for degenerative arthritis of the left knee.

The PEB combined the chronic bilateral knee pain conditions as a single unfitting condition coded 5003 with a 20% rating.  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 therefore 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 DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

The evidence for the bilateral knee pain conditions was presented together above.  In this case, a bilateral condition was addressed in the profile and the bilateral knee pain condition was implicated by the NARSUM and was implicit in the commander’s statement, which referred to the profile.  Members agreed that each knee condition is separately unfitting and that identical coding and ratings are applicable. The Board sought a route to a higher rating and noted that right knee limitation of flexion of 60 degrees only warrants a 0% rating, while extension limitation of 10 degrees warrants a 10% rating.  Neither of the left knee ROMs rise above a 0% rating.  However, there was painful motion during laxity testing warranting a 10% rating.  Therefore, a 10% rating for each knee is appropriate, albeit using different codes; however, the combination of ratings of 20% affords no advantage to the CI compared to the coding assigned by the PEB.  In the absence of ankylosis (5256), knee impairment (5257), meniscal impairment or removal (5258 and 5259), or tibia and fibular impairment (5262) there was no route to a higher rating for either knee.  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 chronic bilateral knee condition.  

BOARD FINDINGS:  In the matter of the chronic 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 20140514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 19 2016

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008652 (PD201403001)

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
( ) DVA