RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	                               CASE:  PD-2014-03067
BRANCH OF SERVICE:  Army	  SEPARATION DATE:  20050226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Unit Supply Specialist, medically separated for “bilateral knee pain and right anterior leg pain,” with a disability rating of 10%.  

CI CONTENTION:  The applicant requested consideration of 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 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 - 20050124	VARD - 20070428	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee and Right Leg Pain	5099-5003	10%	Right Knee ... Right Leg Shin Splints	5020-5260	10%	20070201	
			Left Knee Chondromalacia ...	5260	10%		
Migraine Headache	Not Unfitting	Migraine Headaches	8100	0%		
Asthma		Bronchial Asthma	6602	Deferred		
Bilateral Wrist Pain		Left Wrist Pain	8599-5215	NSC		
		Tendinopathy Right Forearm and Wrist	5024-8515	10%		
Dyspepsia		Esophageal Reflux 	7346	0%		
Chest Pain		Tachycardia	7099-7005	Deferred		
Low Back Pain		Lumbar Strain	5237	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Knee and Right Anterior Leg Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain (diagnosed as patellofemoral syndrome) began in 2001 after running (within months of enlistment).  She developed right leg pain (diagnosed as shin splints) in 2002, also without specific injury.  Earlier treatment notes are missing from the available STR, although a summary NARSUM from the CI’s duty station in Korea referred her for MEB provided details of the clinical course.  Bilateral knee X-rays and a bone scan were reported as normal.  There were no details regarding range of motion (ROM) limitation, effusions, instability, impingement (locking), or gait disturbance from outpatient records in the available STR.  Despite conservative treatment, the bilateral knee and right leg pain could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for MEB.  The MEB forwarded “bilateral knee pain” and “right leg pain” as separate medically unacceptable conditions to the PEB.  The NARSUM examination on 21 December 2004, 2 months before separation, provided separate descriptions of bilateral knee and right leg pain; each “present 100% of the time” and rated “slight and constant;” and, each interfering with running, marching and carrying a rucksack.  The physical examination recorded the absence of effusion or instability and “full” ROM of the knees, and diffuse tenderness of the right leg.  The L3 profile listed separate “bilateral knee pain” and “right leg pain” conditions.  The commander’s performance statement did not provide evidence probative to separate fitness implications of the bundled conditions.

A VA Compensation and Pension (C&P) examination was conducted on 01 February 2007 and, being 2 years after separation, was of limited probative value.  It documented persistent bilateral knee pain and right leg pain that “improved somewhat” since separation.  The physical examination recorded a normal gait and the absence of effusion, instability or impingement.  The bilateral knee ROM was flexion to 150 degrees (normal) and extension minus 5 degrees (0 normal, minus 10 compensable).  Right leg findings were consistent with the diagnosis of shin splints.  

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled both knees and the right shin splint conditions analogously to 5003, for which VASRD §4.71a provides a 10% rating for “2 or more major joints.”  The VA rated the left knee 10% under code 5260 (limitation of flexion) citing painful motion.  The right knee was rated separately at 10%, subsuming the shin splints, under the hyphenated code 5020-5260 (synovitis rated for limitation of flexion).  The Board considered whether each of the bilateral knee and right leg conditions met the Board’s threshold for separate rating (as elaborated above).  In this case there was no evidence that either of the knees was significantly more unfitting than the other, and it was difficult to extricate the contribution from the shin splints from the overall impairment of the right leg.  It was noted the NARSUM separately addressed the right shin splints and separately identified unfitting impairments from that condition; and, the condition was forwarded as such on the MEB’s DA Form 3947.  Furthermore the right leg condition was listed separately on the profile.  It was also considered that there was no other performance based evidence from the available STR.  Members thus agreed the right shin splints condition constituted a distinct separate diagnosis that could not be convincingly excluded as separately unfitting.  Having agreed that the right leg condition should be separately rated, members deliberated the appropriate coding and rating recommendation.  No rating higher than 10% was justified under any §4.71a bone or joint code, but members agreed that a 10% rating was justified by VASRD §4.40 (functional loss) under the analogous code 5099-5022 (periostitis) which is a good clinical fit with the pathology of shin splints.  

The Board next deliberated whether the knee conditions were reasonably justified as separately unfitting for determining whether to recommend a bilateral 10% or separate 10% ratings.  There was no evidence for instability, locking, or frequent effusions which would achieve a rating higher than 10% for either knee; and, there was no evidence contrary to §4.71a criteria for a 5003-based bilateral rating of 10%.  Members agreed, given the pathology and clinical acuity described above, it was reasonable to conclude the performance limitations confined to either knee alone would not have rendered the CI incapable of continuing military service; and, that more likely it was the combined effect of the bilateral condition which rendered her unfit.  Members thus agreed that a bilateral 10% rating was appropriately recommended under code 5024 (tenosynovitis, defaulting to criteria of 5003).  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends separate disability ratings of 10% for the right shin splints condition under code 5099-5022 and 10% for the bilateral knee condition under code 5024.

Contended PEB Conditions.  Migraine headaches, asthma, bilateral wrist pain, dyspepsia, chest pain and low back pain.  The migraine headaches dated to 2002 and were profiled P2 (profile level 2 does not mandate MEB referral and is not generally associated with unfitting conditions).  A neurological addendum to the NARSUM documented incomplete compliance with the prescribed treatment regimen, but noted that the headaches were “somewhat improved in that they are not incapacitating anymore...has not missed work;” and, opined that the condition was medically acceptable.  The commander’s performance statement did not mention headaches.  The asthma, bilateral wrist pain, dyspepsia, chest pain and low back pain conditions were not profiled; were not implicated in the commander’s statement; and, were judged to meet retention standards.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee and right leg condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows:  bilateral knee patellofemoral syndrome coded 5099-5022 with a disability rating of 10%, and right shin splints coded 5024 with a disability rating of 10%; both IAW VASRD §4.71a.  In the matter of the contended migraine, asthma, bilateral wrist, dyspepsia, chest pain and lumbar conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Patellofemoral Pain Syndrome, Bilateral Knees	5024	10%	
Right Shin Splints	5099-5022	10%	
COMBINED	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140627, 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 AR20160013901 (PD201403067)

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