RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03331
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Fire Support Specialist, medically separated for “bilateral knee pain,” with a disability rating of 10%.

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 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

IPEB - Dated 20040308	VA* - (~7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5003	10%	Stress Fracture Left Knee	5257	10%	20041105	
			Stress Fracture Right Knee	5257	10%	20041105	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 6	
RATING:  10%	RATING:  30%	

ANALYSIS SUMMARY:

Bilateral Knee Pain.  The service treatment record indicated the CI first noted knee pain 1998 at which time he was given a temporary profile and was treated with Naproxen (a nonsteroidal anti-inflammatory drug [NSAID]).  An X-ray series in February 2001 indicated the CI had chronic left knee pain for 2 years that came and went in the absence of trauma and was located at the lateral aspect.  X-ray findings demonstrated suprapatellar (above the kneecap) soft tissue fullness suggesting a joint effusion and there were no osseous (bony) abnormalities. Clinically, the impression was a lateral collateral ligament sprain without instability.  Physical therapy was scheduled and subsequently carried out.  By August 2001, the CI complained of bilateral leg/knee pain for several months that became more painful with running.  X-rays revealed bilateral anterior tibial stress fractures.  In December 2001 the CI was diagnosed with bilateral patellar tendonitis and was treated with Ibuprofen (an NSAID), ice, and no running, jumping, marching, or high impact activities.  A limited bone scan in April 2002 revealed mild symmetric patellar stress reactions with asymmetric stress reactions involving the medial compartment of the left greater than the right knee joint.  On 26 June 2002, the CI returned to duty.  An orthopedic evaluation in February 2003 indicated the CI had 2 to 3 years of pain in both knees located just below the joint line and over the kneecaps.  Pain occurred after running, but there was no locking, popping, or giving out.  Braces had been attempted but did not help.  Examination revealed no swelling; the range of motion (ROM) was full; there were no clinical findings of laxity or meniscal tears; and there was moderate tenderness over the patellas and medial upper tibias.  Stress reactions were discussed and a permanent profile was issued.  It was also noted that the CI needed to be pain free for at least 6 weeks before he resumed activities.  A Medical Retention Board, which reviewed the CI’s history and treatment of his bilateral knee pain, noted a permanent profile for bilateral lower extremity stress reactions was issued on 12 March 2003.  

A permanent L3 profile in March 2003 had restrictions of no running, jumping or marching, but the CI could lift up to 40 pounds.  The MEB narrative summary (NARSUM) dated 11 December 2003 (5 months prior to separation) noted the CI with a history of 3 years of bilateral knee pain sought medical attention and underwent physical therapy, activity modification, and had several profiles.  Additionally, he had limited benefit with nonsteroidal anti-inflammatory medication.  Examination of the knees revealed bilateral ROM measurements of 0-130 degrees without effusion.  The bilateral patellae were mobile with significant tenderness on the medial side.  There was crepitus bilaterally with patella motion as well as positive patella grind tests.  There was no joint line tenderness and no ligamentous laxity (Lachman and varus and valgus stress testing were negative as were the posterior drawer tests).  The distal motor and sensory examinations were normal and symmetric and the CI ambulated with a normal gait.  X-rays of the knees in weight bearing views showed moderate degenerative changes of the patellae and minimal changes in the medial joint line without a significant loss of joint height.  The NARSUM examiner opined the CI’s condition was unlikely to improve and unlikely to allow him to continue on active duty military service.  Additional X-rays taken in December 2003 were normal without significant arthritic change.

At the DD Form 2807-1, Report of Medical History, examination dated 9 January 2004, the CI checked off knee trouble, painful joints, and impaired use of arms, legs, hands, or feet on DD Form 2807-1.   The MEB physical examiner did not record any examination findings of the knees or extremities, but did note bilateral lower extremity stress reactions in the summary of defects and diagnoses.  The commander’s statement dated 21 January 2004 indicated the CI was working in an environment that required a minimal amount of physical stamina or strength, but he was unable to perform all duties as a Fire Support NCO or basic soldier skills while complying with the limitations of his profile.  A physical therapy ROM measurements, taken 2 February 2004 (2 months prior to separation), were 120 degrees flexion (140 normal) three times and -5 degrees (0 normal) extension three times.

In June 2004, 2 months after separation (during a family care visit) the CI noted bilateral knee pain for 3 years and requested medication for pain prior to a scheduled VA appointment a week later.  On examination he had no deformity, edema or tenderness to pressure; his gait was without a limp; and he had full active ROMs.  Treatment consisted of Etodolac (a NSAID) and Darvocet-N (a combination of narcotic pain reliever and Acetaminophen which helps to raise the pain threshold).  

At the VA Compensation and Pension (C&P) examination dated 4 November 2004, performed 7 months after separation, the CI reported bilateral stress fractures of both knees for the prior 4 years.  He noted constant pain in both knees with no history of incapacitation.  Bilateral knee examinations were within normal limits with flexion 0-140 degrees and extension 0 degrees.  The ROMs were not further limited by pain, fatigue, weakness, lack of endurance or incoordination.  There was no ankylosis.  Bilateral drawer (to determine laxity) and McMurray signs (to determine meniscal tears) were negative and there was questionable left knee crepitus (grinding sensation).   X-rays of the left and right knees taken in November 2004 also were normal.  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)	MEB ~5 Mo. Pre-Sep	PT ~2 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	130	130	120	120	140	140	
Extension (0 Normal)	0	0	-5	-3	0	0	
Comment	No joint line tenderness or laxity	Hyperextension	Hyperextension	DeLuca negative; no laxity; questionable crepitus	DeLuca negative; no laxity	
§4.71a Rating	PEB 10%	(PEB 10%) 0%	VA 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5003 (Degenerative arthritis) for bilateral knee pain.  The VA assigned a 10% rating using code 5257 (Knee, Other impairment:  subluxation or lateral instability) for a stress fracture of the left knee and a 10% rating using code 5257 for a stress fracture of the right knee.  The Board sought a route to a higher rating and noted the PEB use of code 5003 presumably based on X-ray evidence of involvement of two or more major joints rated at 10% since neither the MEB nor the VA ROM measurements were ratable IAW limited motion of either flexion or extension.  In the absence of incapacitation, a 20% rating using code 5003 based on X-ray evidence is not applicable.  Therefore, the Board considered whether the analogous code 5099-5003 would offer a route to a higher rating.

The PEB combined the left knee pain and the right knee pain under a single service rating, coded 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single service disability rating must be reasonably justified as separately unfitting in order to remain eligible for service rating.  The Board’s initial charge in this case was directed at determining whether the PEB’s combined adjudication was justified in lieu of separate ratings.  In this case, the bilateral (left knee and the right knee) knee condition was profiled, albeit under using the phrase “lower extremity stress reactions,” was considered to fail retention standards, and was implicated by the NARSUM and in the commander’s statement indirectly by referring to his profile limitations.  Members agreed that each joint is separately unfitting and that identical coding and ratings are applicable.  In view of noncompensable ROMs and objective pain (positive patella grind tests) noted on the MEB examination more proximate to separation than the VA examination where no pain on motion was reported, use of the analogous code 5009-5003 at 10% for each knee is reasonable.  In the absence of ankylosis, subluxation, or meniscal involvement no higher rating is possible.  However, the Board did discuss analogous code 5299-5262 (Tibia and fibula impairment) in view of the CI’s history of stress fractures and patellar stress reactions where slight knee involvement would warrant a 10% rating for each knee and moderate knee involvement would warrant a 20% rating for each knee, but there was insufficient evidence to suggest moderate knee involvement based on X-ray studies proximate to separation and use of the analogous code for mild knee involvement affords no greater benefit to the CI than use of code 5099-5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommended a disability rating of 10% for the left knee condition and a disability rating of 10% for the right knee condition.

BOARD FINDINGS:  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 a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a for the left knee pain condition.  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	RATING	
Right Knee Pain	5099-5003	10%	
Left Knee Pain	5099-5003	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140617, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160007973, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result In any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical
Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,

 
XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure