RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03529
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Satellite Communications Systems Operator/Maintainer, medically separated for “chronic bilateral knee pain,” with a disability rating of 0%.  

CI CONTENTION:  The CI requested that the Board review all of his 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 - 20031107	VARD - 20050210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Patellofemoral Pain Syndrome, Right Knee	5014-5260	10%	20040902	
			Patellofemoral Pain Syndrome, Left Knee	5014-5260	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously 5099-5003 (degenerative arthritis) and rated 0% with application of the USAPDA pain policy AR 635-40 B24.f.  The approach by the PEB not uncommonly 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 also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements and that this approach does not 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 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.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began approximately 1 year after service entry (1997) without specific injury.  A diagnostic arthroscopy of the right knee in January 2003 found no underlying joint pathology, however, a diagnosis of patellar tendonitis was made with debridement performed during the arthroscopy.  There was no further surgical indications, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral knee pain (slight/intermittent)” for PEB adjudication.  The MEB NARSUM examination was performed in September 2003 (5 months pre-separation).  The CI reported morning stiffness, and daily pain worsened by prolonged sitting or standing.  Physical examination showed normal gait with no evidence of swelling, crepitus, no evidence of pain with lateral and medial strain, or evidence of meniscal injury.  Range of motion was 5-130 degrees (normal 0-140).  

At the VA Compensation and Pension (C&P) examination on 2 September 2004 (6 months post-separation), the CI reported right knee pain with no improvement following arthroscopy.  The pain was constant, and worsened by maneuvering stairs, standing greater than 30 minutes, or walking more than 15 minutes.  He denied lateral instability, severe flares of pain, weakness, fatigability, and incoordination.  Physical examination showed a normal gait, and pain free range of motion of 0-120 degrees.  There was no evidence of crepitation, meniscal injury, effusion, instability, weakness, or decrements in range of motion after repetition.  There was mild pain at the inferior aspect of the patella with resisted motion.  Radiographic evaluations were normal.  

Chronic Left Knee Pain.  According to the STR and MEB NARSUM, left knee pain began in 1998 after a twisting injury.  Radiographic imaging (1999) of the bilateral knees were normal.  Two clinical entries (family practice and physical therapy) in June 2002 (20 months pre-separation) documented full range of motion (ROM).  Crepitus was noted at one visit.  An orthopedic visit in June 2002 documented a diagnosis of patellar tendonitis.  Radiographic imaging (CT) in November 2002 (15 months pre-separation) documented a normal patellofemoral joint.  At a physical therapy (PT) visit in May 2003 (9 months pre-separation), the CI reported left knee pain worse than the right.  At a primary care visit in June 2003, the physical examination showed crepitation, patellofemoral tenderness (medially and laterally), stable ligaments and no evidence of meniscal injury.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The left knee was also forwarded by the MEB for PEB adjudication.  PT ROM in August 2003 (6 months pre-separation) showed a normal gait, knee ROM of 5-130 degrees (normal 0-140) without pain.  

The MEB NARSUM examination was performed in September 2003 (5 months pre-separation).  The CI reported morning stiffness, and daily pain worsened by prolonged sitting or standing.  Physical examination showed normal gait with no evidence of swelling or crepitus, no pain with lateral and medial strain, and no evidence of meniscal injury.  Range of motion was 5-130 degrees (normal 0-140).  

At the VA Compensation and Pension (C&P) examination on 2 September 2004 (6 months post-separation), the CI reported left knee pain.  Arthroscopy was reportedly offered for the left knee, but the CI declined.  The pain was constant, and worsened by maneuvering stairs, standing greater than 30 minutes, or walking more than 15 minutes.  He denied lateral instability, severe flares of pain, weakness, fatigability, and incoordination.  Physical examination showed a normal gait, and pain free ROM of 0-120 degrees.  There was no evidence of crepitation, meniscal injury, effusion, instability, weakness, or decrements in range of motion after repetition.  There was mild pain at the inferior aspect of the patella with resisted motion.  Radiographic evaluations were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10% coded analogously 5099-5024 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA rated the left and right knee conditions separately at 10% each, analogously coded 5014-5260 (traumatic arthritis; limitation of flexion), citing limitation of motion of both knees.  The Board first considered whether each knee condition remained separately unfitting, having been de-coupled from the combined PEB adjudication.  The bilateral knees were profiled.  They were both implicated in the commander’s statement and by the NARSUM examiner, and forwarded by the MEB.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties. The Board noted that the PEB rated the bilateral knee condition as a single condition.  The Board observed that even if each knee was determined to be separately unfitting, the evidence does not support separate compensable ratings for each knee.  As noted above, there were no distinctions with regards to clinical features or fitness considerations between the right and left knees.  Although the CI was undergoing an MEB for “bilateral knee pain,” there was no documentation of painful motion, painful gait, and no radiographic evidence of arthritis.  

Members debated if 0% was warranted for each leg or if application of §4.40 (functional loss) or §4.59 (painful motion) justified separate 10% ratings.  In this case, limitations of motion alone without documentation of painful motion did not provide sufficient grounds for other rating schemes.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate knee disability ratings.  A bilateral diagnosis supports a single 5003 based rating for “2 or more major joints” without evidence of compensable limitations or painful motion.  Board members agreed that a bilateral rating of 10%, coded analogously 5299-5024, supported both the pathology and disability and that there is VASRD §4.71a latitude for a bilateral rating.  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 bilateral knee pain condition, coded 5099-5024.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain condition, the Board unanimously recommends a disability rating of 10% for the bilateral knee condition analogously coded 5099-5024, 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 Bilateral Knee Pain	5099-5024	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

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, AR20160017504 (PD201403529)

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.

CF: 
(  ) DoD PDBR
(  ) DVA