RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03400
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Equipment Recorder/Parts Specialist, medically separated for “chronic bilateral knee pain,” with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board 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 - 20040901	VARD - 20050321	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Right Knee Myxoid Degeneration of Meniscus	5010	10%	20041229	
			Left Knee Chondromalacia of Patella	5024	10%	20041229	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral knee condition began approximately 10 months prior to referral for MEB.  A left knee X-ray was normal.  A bone scan showed minimal prominence of bone activity at left tibial tuberosity (oblong elevation at proximal anterior tibia where patellar tendon attaches).  At a physical therapy (PT) encounter the CI reported a 3-month history of bilateral (L>R) knee pain with no known mechanism of injury.  He complained of constant 8-10/10 left knee and intermittent 5/10 right knee pain.  Pain was exacerbated by running and prolonged standing and relieved with rest.  The CI reported associated minimum swelling, buckling, and locking.  They physical exam revealed an antalgic gait.  The bilateral knee exam revealed tenderness (L>R).  There was pain associated with valgus/varus stress (assesses medial collateral ligament [MCL]/lateral collateral ligament [LCL]), Lachman (assesses anterior cruciate ligament [ACL]), McMurray (assesses menisci), and patellar grind (assesses abnormal patellar movement and painful crepitation) tests.  The range of motion (ROM) was right knee flexion of 125 degrees (140 normal) with extension of 0 degrees (0 normal) and left knee flexion of 75 degrees (140) with extension of 0 degrees (0 normal).  The therapist recounted the findings of the X-rays and bone scan.  The assessment listed bilateral knee pain.  A left knee magnetic resonance imaging (MRI) showed advanced tendinosis (chronic tendon degeneration without inflammation) of the posterior horn of the medial meniscus (knee semilunar cartilage).  A subsequent left knee MRI showed a small joint effusion (fluid collection) and chondromalacia patella (pathologic changes in patellar articular cartilage).  A right knee MRI showed findings suggestive of myxoid degeneration (tissue deterioration to a lower or less functionally active form) of the posterior horn of the medial meniscus, but was otherwise unremarkable.  

The NARSUM performed 4 months before separation, recounted the history and interventions.  The CI reported onset of left knee pain at the end of basic training.  He developed bilateral knee pain during Advanced Individual Training.  The CI complained of constant bilateral knee pain (L>R).  The pain was posterior to the patellae and at the medial and lateral joint lines.  Pain was characterized as throbbing with associated daily left knee swelling, buckling, and stiffness.  Pain was exacerbated by prolonged sitting, prolonged standing, prolonged walking, running, jumping, squatting, pushups, sit-ups, ruck marching, and carrying greater than 30 pounds.  He used a knee brace and a cane for ambulation.  Orthopedic surgery diagnosed him with patellofemoral pain syndrome and tibial band pain and recommended PT and nonsteroidal anti-inflammatory drugs (NSAIDs).  The CI failed conservative management which included activity modification, crutches, PT, and NSAIDs.  The physical exam documented an antalgic gait.  The bilateral knee exam revealed medial and lateral joint line tenderness and a mild right knee effusion.  There was pain associated with valgus/varus stress, McMurray, and patellar grind tests.  The goniometer measured ROM was right knee flexion of 125 degrees with extension of 0 degrees and left knee flexion of 100 degrees with extension of 0 degrees.  There was pain with ROM.  Strength and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the X-rays, bone scan and MRIs.  Pain was rated as constant and slight.  The diagnoses listed left knee pain with chondromalacia patella and right knee pain with right medial meniscal myxoid degeneration.  

The VA Compensation and Pension (C&P) examination in December 2004, performed 2 months after separation, recounted the history and interventions.  The CI reported knee pain began in basic training and was not due to injury.  He complained of constant knee pain and stiffness.  Pain was exacerbated by prolonged walking, running, and stairs.  The knee condition did not cause incapacitation or result in any time lost from work.  The physical exam documented a normal gait with no assistive device.  The bilateral knee exam revealed normal general appearance and right knee locking pain.  The drawer (assesses ACL/PCL) and McMurray tests were negative.  The active ROM was right knee flexion of 120 degrees with extension of 0 degrees and left knee flexion of 130 degrees with extension of 0 degrees.  Following repetitive use, ROM was additionally limited by pain, with pain having the major functional impact.  Following repetitive use, ROM was not additionally limited by fatigue, weakness, lack of endurance, or incoordination.  Strength and sensation were normal.  The examiner recounted the findings of the MRIs and the right and left knee X-rays were normal.  The diagnoses listed left knee chondromalacia patella and right knee myxoid degeneration of meniscus.

The Board directed attention to its rating recommendation based on the above evidence.  The Board must first consider whether each knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis) citing application of the US Army Physical Disability Agency pain policy.  The VA assigned a 10% rating for the right knee using the 5010 code (arthritis due to trauma) and a 10% rating for the left knee using the 5024 code (tenosynovitis) based on the VA C&P exam 2 months after separation, citing limited and painful motion.  The proximate (NARSUM and C&P) exams did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  While there was right medial meniscal myxoid degeneration, there was no dislocated meniscus (5258) or symptomatic removed meniscus (5259) for consideration under the respective codes.  There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  The Board carefully considered the option of rating both knees together, noting that the VA rated each knee separately.  Members debated if 10% was warranted for the bilateral knees or if application of §4.40 (functional loss) or §4.59 (painful motion) justified separate 10% ratings.  The Board concluded that the evidence did provide sufficient grounds for recommending separate knee disability ratings in this case.  A rating of 10% for the right and 10% for the left, coded 5099-5003, is a good analogy to both the pathology and disability.  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 right knee condition and 10% for the left knee condition, coded 5099-5003. 

BOARD FINDINGS:  In the matter of right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of left knee condition, the Board unanimously recommends a disability rating of 10%, 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	PERMANENT RATING	
Chronic Right Knee Pain	5099-5003	10%	
Chronic Left Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140721, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160008007, 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 Iaccept 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,