RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03678
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-4, Food Service Specialist, medically separated by the Informal Physical Evaluation Board (PEB) for “chronic bilateral knee pain” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  The applicant’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 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 – 20011102	VARD - 20020222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Right, Patellofemoral Pain Syndrome	5024	10%	20011207	
			Left, Patellofemoral Pain Syndrome	5024	10%	20011207	
RATING:  10%	RATING:  20%	

ANALYSIS SUMMARY:  

Bilateral Knees.  The Medical Evaluation Board (MEB) narrative summary (NARSUM) noted the CI developed bilateral knee pain without specific trauma in approximately 1999.  Notes in the service treatment record indicate the CI was diagnosed with retropatellar pain syndrome (RPPS), right greater than left.  The knees initially improved, but at a primary care evaluation on 11 May 2000, the CI reported the right knee pain increased without any inciting event.  The exam noted an antalgic gait and complete right knee exam was normal except for tenderness to palpation (TTP) of the anterior knee.  The CI was seen by physical therapy (PT) for right knee pain without improvement through 5 September 2000, with gradual onset of left knee pain.  An orthopedic evaluation 14 September 2000 noted bilateral knee range-of-motion (ROM) of 0-130 degrees, without effusion or evidence of instability.  Knee X-rays were normal bilaterally, without evidence of degenerative joint disease.  The orthopedic specialist assessment was no surgery was indicated and recommended permanent profile and an MEB if the CI was unable to perform in her military occupational specialty (MOS).  The bilateral knee pain was unrelieved by conservative management including profiles, medications, and PT and an MEB was initiated.

At the MEB exam on 24 September 2001, 4 months before separation, the CI reported bilateral knee pain aggravated by activities such as squatting, kneeling, walking, running, or standing more than 15 minutes.  The MEB physical exam was reported for the bilateral knees and noted bilateral ROM of extension-flexion of 0-130 degrees (normal 0-140).  There was no TTP of the joint lines or instability of the knees and strength, sensation, reflexes and pulses of both lower extremities were normal.  At the VA Compensation and Pension (C&P) exam on 7 December 2001, 2 months before separation, the CI reported constant bilateral knee pain, increased with activity.  The exam noted an antalgic gait favoring the right.  The bilateral knees were TTP, with slight swelling and painful, full ROM.  Muscle strength, sensation, and reflexes were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the bilateral knee condition 5099-5003, rated 10%, and cited the USAPDA pain policy.  The VA rated the right and left knees each 10%, both coded 5024 (Tenosynovitis).  The Board first attempted to unbundle the right and left knee conditions to see if each knee remained reasonably justified as unfitting as indicated above.  The permanent profile listed “anterior knee pain (RPPS).”  Both the right and left knees were diagnosed with RPPS in the STR.  The commander’s statement noted “knee injury” and noted the CI’s inability to lift and stand as need impaired her duty performance.  Both knees were addressed by the orthopedic consult that recommended the permanent profile and an MEB if indicated, though the right knee was worse than the left.  The Board noted that the functional limitations of both knees were the same, and the earlier profiles for the right knee therefore, protected the left knee as well.  Member consensus was that the functional limitations in evidence justified the conclusion that the both the right and left knee conditions were integral to the CI’s inability to perform her MOS; and, accordingly a separate service rating is recommended.

The Board first considered the rating of the right knee condition.  Members agreed that the evidence supported a 10% rating, with a knee ROM code, based upon considerations of VASRD §4.59 (Painful motion) and VASRD §4.40 (Functional loss) due to pain, increased by activity documented throughout the record and painful motion noted at the pre-separation C&P exam.  The Board chose to code the knee condition as 5299-5261 (Analogous for leg, limitation of extension), an analogous code for RPPS, the diagnosis in record.  The Board reviewed to see if a higher rating was supported with any applicable knee code, but there was no evidence of limited leg flexion or extension sufficient to meet a 20% rating; instability; symptomatic semilunar cartilage injury, impairment of the femur, tibia, or fibula; or, ankylosis for a higher rating.  The Board determined that the right knee condition met a 10% rating and no higher, with consideration of functional loss.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt) and §4.40, the Board recommends a disability rating of 10% for the unfitting right knee condition.

The Board next considered the rating of the left knee condition.  The Board noted that the right and left knee conditions were considered together at the orthopedic evaluation noted above and at the MEB NARSUM and C&P exams, with identical physical findings reported for both knees at all exams.  Therefore, by the same rationale as elaborated above for the right knee rating, Board members agreed that the evidence supports a 10% rating for the left knee for pain with use/painful motion coded as 5299-5261 and no higher, including consideration of functional loss.   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt) and §4.40, the Board recommends a disability rating of 10% for the unfitting left knee condition.

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends a disability rating as follows: unfitting right knee condition rated 10%, and unfitting left knee condition, rated 10%, both coded 5299-5261 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 her prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Right Knee Pain Condition	5299-5261	10%	
Chronic Left Knee Pain Condition 	5299-5261	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140722, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160005140
(PD201403678)

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