RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03062
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20000524	
DATE REMOVED FROM TDRL:  20011206

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Heavy Anti-Armor Weapons Infantryman, medically separated from the Temporary Disability Retired List (TDRL) for “bilateral knee pain with no instability” with a disability rating of 0%.

CI CONTENTION:  The CI contends his conditions have worsened and wants all conditions considered.  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 – 20000208/20011031	VARD - 20000601	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Right Retropatellar Pain Syndrome…	5261	30%	0%	Retropatellar Pain Syndrome, Right Knee	5099-5024	10%	10%	
Pain Left Knee…	5099-5003	10%		Retropatellar Pain Syndrome, Left Knee	5099-5024	0%	0%	
COMBINED RATING:  40% → 0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain with No Instability.  The service treatment records and MEB narrative summary (NARSUM) indicated the CI had a history of recurrent and chronic bilateral knee pain as a result of trauma during airborne operations in 1998.  X-rays of the right and left knees were normal.  He was diagnosed with retropatellar pain syndrome (RPPS) not amenable to surgery.  Despite multiple physical therapy treatments and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), the CI continued to have knee pain.  A bone scan in May 1999 suggested a stress fracture of the right medial tibial plateau and an older stress fracture of the left medial tibial plateau.  X-rays of the right and left knees in April 2000 were normal.  

At the MEB examination dated 20 October 1999 the CI checked ‘yes’ to “trick” or locked knee on SF 93, Report of Medical History.  The examiner noted a positive grind test and right knee flexion 20-110 degrees and left knee flexion 5-110 degrees with an inability to fully extend the knees bilaterally.  At the NARSUM examination dated 25 October 1999 physical findings were the same as the MEB examination above and there was a positive grind test on the knees bilaterally.  Physical therapy measurement results were of the right knee flexion 20-110 degrees and left knee flexion 5-110 degrees.  However, the CI was unable to extend either knee secondary to pain.  Tests for laxity (drawer test) and a meniscal tear (McMurray’s) were negative.  The NARSUM diagnosis was RPPS bilaterally.  A permanent L3 profile was approved on 2 November 1999 with limitations of no 2-mile run, walk or bicycle for the physical fitness test and no airborne operations or wearing of a backpack.  The commander’s statement date 17 November 1999 indicated the CI’s physical condition did not allow him to accomplish his mission as an infantry soldier, meet the physical fitness standard, or perform his wartime mission.

At the VA Compensation and Pension (C&P) examination dated 4 April 2000, performed less than 2 months before separation, the CI reported both knees hurt, although he felt more discomfort in the right knee and sometimes the knees popped and locked.  Initial X-rays showed no abnormalities and a bone scan showed stress fractures of the medial-tibial plateau.  His gait was normal as were tiptoe walking, tandem walking, and heel walking. Flexion was 140 degrees and extension was 0 degrees bilaterally.  The right knee had minimal pain on flexion.  The left knee had moderate pain at the McMurray to the outside “noting some problem with the medial-lateral ligament” and was negative on the right.  The VA diagnosis was bilateral knees: minimal tendinitis, left knee with a positive McMurray and minimal strain, right knee with pain on flexion.

At the VA C&P TDRL examination dated 2 July 2001 the CI reported pain in both knees that was getting worse with more pain on the right than the left.  Sitting down with the knees bent made the knees stiff and occasionally he felt a popping sensation in the knees.  He took no medication and worked as a horticulturist planting flowers.  On examination he had a normal heel-toe gait and had no knee braces.  Squatting was possible, but he complained of pain in his right knee.  The knees were in a mild varus (inward) position while weight-bearing.  Patellar position was normal and there was no effusion, swelling, or tenderness.  Patella translation was normal and the apprehension test was negative.  There was no joint line tenderness and no laxity or evidence of a meniscal tear; and, the collateral ligaments were stable.  The ROM was 0-135 degrees on the right with complaint of pain and 0-140 degrees on the left without any pain.  Quadriceps muscle tone was good on both sides.  X-rays of the both knees were normal without any evidence of traumatic pathology, while magnetic resonance imaging (MRI) in July 2001 demonstrated moderate knee joint effusions bilaterally.  On the right side there was a small ganglion cyst in close proximity to the semimembranosus tendon and a bone contusion of the tibial plateau along with evidence consistent with a lateral collateral ligament sprain.  On the left side, the cruciate and collateral ligaments, the medial and lateral menisci, and the patellar tendon were normal.  The VA examiner’s diagnosis was a history of injury to the knees with residual sprain of the right knee resulting in cystic swelling most likely a ganglion cyst of the semimembranosus tendon.  The knee joints were stable without any evidence of ligamentous instability or cruciate ligament damage.  The examiner opined the condition was stable and the pain was minimal to moderate and constant and the CI was employable.  The CI rebutted a few points of the examination history and wrote that since discharge his knees seemed to be building up more pressure more frequently and that sitting with his knees straight made them ache.  He also noted cracking of the knees quite often with pressure built up, which was relieved by walking around.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB for TDRL placement assigned a 30% rating using code 5261 (leg, limitation of extension) for right RPPS with inability to fully extend his knee and a 10% rating using code 5099-5003 (degenerative arthritis) for pain left knee.  The VA assigned a 10% rating using code 5099-5024 (tenosynovitis) for retropatellar pain syndrome, right knee and a 0% rating using code 5099-5024 for RPPS, left knee.  The PEB for TDRL removal assigned a 0% rating using code 5099-5003 for bilateral knee pain with no instability IAW USAPDA Policy/Guidance #13.  Board members first discussed whether an alternative or additional rating would be applicable for the PEB TDRL placement.  Members concluded there was no code available to provide a higher rating for the right knee in the absence of ankylosis (code 5256), extension limited to 30 degrees or more (code 5261) or nonunion with loose motion requiring a brace (code 5262).  Likewise for the left knee there was no code available to provide a higher rating in the absence of ankylosis, knee impairment with recurrent subluxation or lateral instability (code 5257), cartilage dislocation (code 5258), flexion limited to 30 degrees or less (code 5260), extension limited to 10 degrees or more (code 5261), or tibia and fibula impairment with nonunion or malunion with moderate knee disability (code 5262).  Board members then discussed the TDRL removal rating and noted the PEB applied a 0% rating for bilateral knee pain.

Board Approach to PEB Consolidated Rating.  The PEB combined the bilateral knee pain conditions as a single unfitting condition coded 5099-5003 and rated the disability 0% as minimal/constant IAW U.S. Army Physical Disability Agency (USAPDA) pain policy.  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 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 alluded to in the profile with the diagnosis of RPPS and the bilateral knee pain conditions were implicated by the NARSUM and implied in the commander’s statement.  Members agreed that each knee condition is separately unfitting and that identical coding and ratings are applicable.  The right knee had a non-compensable ROM, but pain was present and the MRI demonstrated a bone contusion of tibial plateau and suggestive evidence of a lateral collateral ligament sprain.  Therefore, a 10% rating using code 5099-5003 is not unreasonable for the right knee, but there was no other code to warrant a higher rating.  The left knee likewise had a non-compensable ROM, but there was no pain to justify the use of code 5099-5003 at a rating more than 0%, and while there was edema of both knees, there was no meniscal tear or dislocation or frequent locking to use code 5258 or instability to use code 5257.  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 right knee and left knee pain conditions for TDRL placement.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee pain condition and a disability rating of 0% for the left knee pain condition at TDRL removal.  
BOARD FINDINGS:  In the matter of the right and left knee pain conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication for TDRL placement.  In the matter of the right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a; and, in the matter of the left knee pain condition, the Board unanimously recommends a disability rating of 0%, coded 5099-5003 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	RATING	
		TDRL	PERMANENT	
Right Knee Pain	5261	30%	10%	
Left Knee Pain	5099-5003	10%	0%	
RATING (w/ BLF)	40%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140623, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX AR20160013898  (PD201403062)

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 10% 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: