RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03777
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040423

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

CI CONTENTION:  The CI requested 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 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 - 20040309	VARD - 20040927	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Retropatellar Pain Syndrome and Popliteal Cyst, Left Knee	5299-5260	0%	STR	
			Retropatellar Pain Syndrome and Popliteal Cyst, Right Knee	5299-5260	0%	STR	
Bilateral Small Popliteal Cysts	Not Addressed by PEB					
Hearing Loss	Not Addressed by PEB	Hearing Loss	6100	NSC	20040826	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in March 2002 following Primary Leader’s Development Course (PLDC) attendance.  Bilateral knee X-rays in November 2002 did not reveal any fractures, loose bodies, or bony destructive lesions.  An MRI study of his bilateral knees in July 2003 indicated small popliteal cysts (also known as Baker’s cysts - evidence of degenerative changes in knees) with no evidence of meniscal tears, cruciate ligament injury, or chondromalacia.  The CI was diagnosed alternately in the STR with retropatellar pain syndrome (RPPS) or patellofemoral pain syndrome (PFPS) and there was no surgical indication.  Despite treatment, the bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral knee retropatellar femoral pain syndrome, pain is slight and constant” for PEB adjudication.  

The permanent profile listed “chronic knee pain.”  The commander’s statement did not indicate specific medical diagnoses, but noted the CI was unable to perform Army physical fitness testing, although the permanent profile listed an alternate APFT event of walking was approved.  

The range of motion (ROM) examinations 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 ~4 Mos. Pre-Sep
	VA C&P ~5 Mos. Post-Sep
	
	Left	Right	Left	Right	
Flexion (140 Normal)	140	140	100	90	
Extension (0 Normal)	0	0	0	0	
Comment	Normal gait
Stable
Mild patellar grind 	Normal gait
Painful motion Crepitus 2+ Tenderness 
Stable	Normal gait Painful motion Tenderness 
Stable	
§4.71a Rating	10% (PEB 0%)	10% (PEB 0%)	10% (VA 0%)	10% (VA 0%)	

At the MEB NARSUM examination in December 2003, performed 4 months prior to separation, the CI reported bilateral knee pain that was slight and constant.  Physical exam noted a normal gait.  There was tenderness behind both patellae with normal patellar tracking and positive patellar grind test (pain with patellar “grinding”).  Bilateral knee ROM was normal, with painful motion.  There was no evidence of instability or meniscal pathology.  At the MEB examination (recorded on the DD Forms 2807 and 2808) dated January 2004, 3 months prior to separation, the CI reported continuous swollen and painful knees that occasionally locked up.  Physical exam noted bilateral knee pain with stable knees and no effusions.  

At the VA Compensation and Pension (C&P) examination in September 2004, performed 5 months after separation, the CI reported constant bilateral knee pain with no incapacitating episodes or flare-ups.  He denied use of a cane or a crutch.  Physical exam showed a normal gait.  Right and left knee ROM was as indicated in the chart above, with painful motion.  There was no evidence of instability.  Bilateral knee X-rays were normal.  

The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 10% with application of the US Army Physical Disability (USAPDA) pain policy.  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 directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (arthritis, degenerative), citing the USAPDA Pain Policy.  The VA assigned a 0% rating to each knee using an analogous 5299-5260 code (leg, limitation of flexion of) citing STRs as the CI failed to report for two VA C&P examinations.  However, the file contained the VA exam quoted above, but it was not identified in the original or any subsequent VA Rating Decisions.  

The Board 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.  Treatment visits in the STR addressed both knees; both knees were evaluated by MRI and diagnosed with RPPS/PFPS.  The NARSUM indicated the CI failed retention standards due to bilateral RPPS.  The permanent profile physical limitations could be attributed to both knees equally and the commander’s statement did not provide additional information to discriminate the fitness implications of each knee.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that each bundled knee condition is reasonably considered separately unfitting.  The ratable criteria in evidence for each knee are the same and the Board therefore considered its rating recommendations for both knees at the time of separation together below.  

A bilateral 10% rating under the provisions of 5003 was considered for pathology of both knees (with MRI evidence of degenerative changes), but it was concluded that the MEB NARSUM exam and VA exam cited above provided satisfactory evidence for painful motion of both knees; thus, separate 10% joint ratings are indicated IAW §4.71a, coded 5099-5003 or coded as 5299-5261 (analogous to limited leg extension, also an analogous code for RPPS) in accordance with VASRD §4.59 (Painful motion).  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that each knee be separately unfitting with a disability rating of 10% for the left knee and 10% for the right knee condition; each coded 5099-5003.  

Contended PEB Conditions.  Bilateral Small Popliteal Cysts and Hearing Loss.  The popliteal cysts are MRI findings of each knee that are “imaging evidence” of degenerative changes within the knees.  The popliteal cysts do not provide functional impairment of the knees which could be considered separately unfitting apart from the RPPS of both knees and any related disability due to the popliteal cysts is subsumed in the rating of the knees noted above IAW VASRD 4.71a.  A single note in the STR dated 19 September 2001 indicated that the CI reported decreased hearing for 2 months.  He was referred for an audiology consult.  There are no records of an audiology consult or audiogram near that time in record.  The hearing loss was given an H2 profile and was not implicated in the commander’s statement.  

The popliteal cysts were not permanently profiled.  As noted, the hearing loss was given a “2” profile, which signifies a condition which requires some physical limitations, but is not in all cases disqualifying for continued military service.  Neither condition was implicated by the commander’s statement, nor was there performance-based evidence from the record that either condition significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended small popliteal cysts and HL conditions, the Board unanimously agrees that it cannot recommend either condition for additional 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 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 20140725, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160011594 (PD201403777)

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