RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03268
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Communications Specialist, medically separated for “second degree AV [atrioventricular] block” (heart rhythm disturbance, generally benign) and “chronic bilateral knee pain due to chondromalacia” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “…I was only awarded 10% for a heart problem, high blood pressure and joint issues in both knees at the time of separation.”  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 - 20060320	VARD - 20070212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Second Degree AV Block	7015	10%	Second Degree AV Block	7015	0%	20061211	
Chronic Bilateral Knee Pain Due to Chondromalacia	5099-5003	0%	Tendonitis Right Patella	5099-5014	10%	20061211	
			Left Knee Chondromalacia	5099-5014	0%	20061211	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Second Degree AV Block.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented in 2004 with a complaint of chest pain.  A cardiac work-up was normal except for a second degree AV block (Mobitz I), a finding generally considered to be benign.  He was cleared for a subsequent deployment to Iraq but was evacuated with episodes of chest pain and “passing out.” Exhaustive cardiac and pulmonary evaluations ensued after re-deployment (including cardiac catheterization), and all studies were normal except for an intermittent second degree AV block on Holter monitor (asymptomatic).  An exercise stress test yielded normal results to a tolerance of 13.7 METS (metabolic equivalent units applicable to VASRD rating), and there was no evidence of cardiac hypertrophy or dilatation on any study.  Consultants opined that the AV conduction disturbance was benign (a normal variant per one cardiologist), unlikely to be the cause for the CI’s symptoms, and that he was cleared for full activity from a cardiac standpoint.  The CI was started on medications for his high blood pressure, one of which (filodipine, a calcium channel blocker) had anti-arrhythmic properties (relevant to PEB rating rationale).  Symptoms persisted which interfered with satisfactory duty performance and the CI was referred for an MEB, which in turn forwarded “second degree AV block, Mobitz type I” to the PEB.

The NARSUM examination on 24 February 2006 (4 months prior to separation) thoroughly detailed the above clinical course, ancillary results and specialty opinions; and stated, “Patient still having some chest pain when he feels that he has arrhythmias ....”  There were no pertinent findings on physical examination.  

A VA Compensation and Pension (C&P) examination on 11 December 2006 (6 months after separation) documented the clinical course and associated symptoms, but did not comment on current symptoms, and listed current treatment as none.  There were no pertinent findings on physical examination.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated under code 7015 (atrioventricular block) which is specific to the condition.  Members agreed, therefore, that it was not justified to leverage an alternate code to achieve a higher rating.  The 10% criteria of 7015 are “workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication or a pacemaker required.”  The 20% criteria are “workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray.”  There was no evidence in support of any 20% criteria.  The PEB conceded “continuous medication required” as a 10% criterion.  The VA, referencing the C&P evidence, specified that none of the 10% criteria, including continuous medication, were satisfied in justification of its 0% rating.  Members agreed that in fairness the PEB’s 10% rating should be conceded.  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 of the cardiac condition.  

Bilateral Knee Pain.  The STR indicated an initial complaint of left knee pain in 2003, with a follow-up note.  All subsequent outpatient entries in the available STR addressed only the right knee, and only the right knee was X-rayed (normal).  The MEB’s DD Form 2807-1, Report of Medical History, (29 November 2005, 7 months prior to separation) did record a complaint of “both knees lock and give out.”  An orthopedic entry 6 days later recorded a presentation for “right anterior knee pain - insidious.  Denies locking/giving away/effusions.”  That examination recorded a normal gait and findings (bilateral) of no atrophy, no effusion, stability to stress testing in all planes, and negative signs of impingement (locking).  The range of motion (ROM) was described as grossly normal for the left knee and measured for the right knee: flexion to 135 degrees (normal 140, 45 for minimum 10%) and extension 0 degrees (normal).  The orthopedist’s diagnosis was patellar chondromalacia.  There was no evidence from other STR entries contrary to these findings.  There was no surgical indication, and conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The CI was referred for an MEB which forwarded “bilateral knee pain” to the PEB.

The NARSUM (11 weeks after the above orthopedic consultation) documented “increased pain right greater than left knee” precipitated by “walking half a mile, climbing steps, climbing into vehicles, and bending.”  The physical examination recorded bilateral tenderness, the absence of effusion, stability to stress testing in all planes, and negative signs of impingement.  Bilateral ROM was flexion to 135 degrees and extension 0 degrees. 

The permanent L3 profile (3 months prior to separation) listed “bilateral knee pain,” although only the right knee was listed on the preceding profile.  The commander’s performance statement was not probative to separate fitness implications of either knee or whether the condition was unilateral or bilateral.

The 6-month after separation VA C&P examination (same as for cardiac condition) addressed separate right and left knee conditions.  For the right knee the CI reported twice weekly flares (2-hour duration) rated 7/10 and necessitating the use of a cane and brace; and, for the left, “mild pain and popping.”  The examiner opined that there was no occupational impairment for either knee.  The VA physical examination recorded a normal gait, tenderness of the right but not left knee, no atrophy or effusion, and bilateral stability to stress testing with negative signs of impingement.  The VA ROM measurements were bilateral flexion to 140 degrees and extension 0 degrees; specifying painful motion on the right, but no painful motion on the left, and no ROM degradation with repetition for either knee (negative DeLuca factors).     

The Board directed attention to its recommendations based on the above evidence.  The Board provides the following clarification concerning its approach to PEB consolidated ratings.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 (degenerative arthritis) and rated 0%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of knee conditions was unfitting and there was no need for separate fitness adjudications. The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under VASRD 5003 criteria, and that this approach does not necessarily compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining whether 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 VA separately coded each knee as 5099-5014 (analogous to osteomalacia, defaulting to criteria of 5003); rating the right knee 10% for painful motion and the left knee 0% based on the lack of any compensable criteria from the C&P examiner.  The PEB’s bilateral 0% rating did not comport with VASRD §4.71a which confers a 10% rating under 5003 for the involvement of “2 or more major joints” without specifying a need for additional criteria.  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%.  

The Board then considered whether or not the knees were reasonably justified as separately unfitting as a basis for recommending separate ratings (as elaborated above).   The evidence makes clear that the right knee was associated with significantly more disability than the left one in this case.  The disparity was such that the question was raised of whether the left knee was reasonably justified as separately unfitting.  It was the right knee that was profiled and the focus of treatment leading up to the MEB that was initiated for the heart condition, and remained so throughout most of the MEB period.  Members agreed that, given the above evidence from the orthopedic consult, it was improbable that the left knee would have itself been subject to an MEB; and, that there was scant, if any, probative evidence implicating the left knee as unfitting, either in isolation or in combination with the other knee.  Members therefore agreed that there was insufficient performance based evidence to support a conclusion that the functional impairment from the left knee would have rendered the CI unable to perform his MOS; and, accordingly cannot recommend a separate Service rating for it.  

Having so concluded, members turned to deliberation of the appropriate coding and rating recommendation for the unfitting right knee.  As above, no criterion is in evidence which would satisfy a rating higher than 10% under any applicable code available in VASRD §4.71a; but, members agreed that VASRD §4.59 (painful motion) and/or §4.40 (functional loss) was reasonably conceded in support of the minimum compensable 10% rating.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the right knee condition; proposing code 5099-5014 (as per VA) for its clinical compatibility.

BOARD FINDINGS:  In the matter of the second degree AV block and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the combined bilateral knee condition, the Board unanimously recommends a rating of 10% for an unfitting right knee condition coded 5099-5014 IAW VASRD §4.71a; but, unanimously agrees that the left knee condition is not reasonably justified as separately unfitting and thereby not subject to disability rating.  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 his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Second Degree Atrioventricular Block, Mobitz I	7015	10%	
Patellar Chondromalacia, Right Knee	5099-5014	10%	
Chronic Pain, Left Knee 	Not Unfitting	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140714, 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 AR20160013911 (PD201403268)

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