RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-04096
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Explosive Ordnance Disposal Specialist) medically separated for chondromalacia, bilateral knees.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left knee chondromalacia and patellofemoral syndrome” and “right knee chondromalacia and patellofemoral syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chondromalacia, bilateral knees, with persistent symptoms, status post debridement of the left medial meniscus,” as unfitting, rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He had several other conditions not evaluated and his condition continues to worsen.  His complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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/Naval 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 20071025	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia, Bilateral Knees, with Persistent Symptoms, Status Post Debridement of the Left Medial Meniscus	5099-5003	0%	Chondromalacia, Bilateral Knees, with Persistent Symptoms, Status Post Debridement of the Left Medial Meniscus	5260	10%	20080123	
			Chondromalacia and Patellofemoral Syndrome, Right Knee	5260	10%	STR	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 0	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080226 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  The PEB combined bilateral knee conditions as a single unfitting condition coded 5099-5003 (analogous to degenerative arthritis) and rated 0%, with application of the USAPDA pain policy and 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’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 Disability Evaluation System 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.  

Bilateral Knee Conditions.  The narrative summary (NARSUM) noted the CI developed bilateral knee pain without specific traumatic incident.  The CI first reported left knee pain in April 2006 and within a few months he reported right knee pain.  Both knees were diagnosed as patellofemoral syndrome (PFPS) and treated conservatively.  The CI was initially referred to orthopedics and bilateral knee exam 8 March 2007 was normal.  The orthopedic specialist referred the CI to rheumatology to rule out a systemic inflammatory disorder and the evaluation was negative.  In the interim the CI had magnetic resonance imaging (MRI) of the right and left knees on 26 March 2007, which reported non-displaced medial meniscal (semilunar cartilage) tears (MMT) of both knees.   The CI was referred back to orthopedics for consideration of surgical treatment of the MMTs.  The left knee symptoms were worse than the right and the CI underwent arthroscopy on the left knee 8 May 2007.  No meniscal tear (MT) was noted during the procedure, but debridement of some joint soft tissue (synovial plica) was performed.  The left knee pain failed to improve after the surgery.  No further surgery was recommended for either the left or right knees and an MEB was initiated.  

Three temporary profiles between 19 March and 25 July 2007 listed the bilateral knee conditions.  The commander’s statement dated 2 July 2002 did not specifically identify the CI’s medical conditions, but noted that his profile and physical limitations, which applied equally to both knees, impaired the performance of the duties of his MOS, general activities required of all soldiers, and physical fitness testing.  An orthopedic memorandum to the PEB 30 August 2007 indicated that bilateral knee pain impaired the CI’s ability to safely perform his job.  The permanent profile 4 October 2007 listed chondromalacia and PFPS of the left knee and the right knee.  At the MEB exam 4 October 2007, the CI reported pain in both knees.  The MEB physical exam was reported for the bilateral knees.  There was tenderness to palpation of both knees and pain and crepitus with patellar compression/grind.  There was mal-tracking of the patella with extension (positive J sign) noted, but no anterior-posterior or lateral instability of the knee joint.  The range-of-motion (ROM) of both knees was 0-120 degrees (normal 0-140).  The MEB examiner indicated that both the left and right knees failed to meet retention standards and noted limitations, which included being unable to run, jump, climb, bend, stoop, ruck march, or stand for more than ten minutes.

At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the CI reported constant bilateral knee pain with weakness, stiffness, giving way and locking aggravated by activity.  He denied swelling or dislocations.  The physical exam noted normal posture and gait.  There was no swelling, effusion, tenderness, crepitus, locking, subluxation or guarding of movement of either knee.  The ROM of both knees was 0-140 degrees.  There was no additional loss of ROM with repetition, but there was painful motion.  There was no evidence of instability or meniscal injury.  After separation, MRI of the right and left knees on 8 September 2008 noted no MTs or any other abnormalities, except minimal joint effusion of both knees.
The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the bilateral knee conditions as a single unfitting condition and rated 0%, coded 5099-5003 (analogous to degenerative arthritis), with likely application of the USAPDA pain policy.  The VA rated the left knee and the right knee each 10%, both coded 5260 (limitation of leg flexion).  

The Board first considered whether each knee remained separately unfitting when considered apart from the PEB’s combined adjudication as established above.  In this case, a bilateral knee condition was noted on multiple temporary profiles, permanently profiled and duty limitations noted in the commander’s statement and the NARSUM applied equally to the left and right knees.  Both knees were addressed at treatment visits in the STR, imaged, addressed by the MEB exam and the orthopedic specialist indicated that bilateral knee pain impaired the CI’s ability to perform his job.  The Board readily agreed the evidence in record supported each knee as reasonably considered unfitting at the time of separation.  The coding and rating features were essentially identical for both knees, therefore the Board considered its rating recommendation for the left and right knee conditions together at the time of separation.  

The Board agreed that the evidence supported a 10% rating for each knee coded 5299-5260, IAW VARSD §4.59 (Painful motion) for painful ROM.  The Board reviewed to see if a higher rating for either or both knees was supported with any other applicable code.  There is no higher rating than 20% combined for both knees coded as a bilateral condition according to 5003 rating criteria.  Although the MRIs during service noted possible MTs, the Board noted that the orthopedic specialist noted no MT of the left knee at arthroscopy, at the C&P exam, there was no clinical evidence of meniscal injury of either knee, and post-separation MRI imaging of both knees showed no MT.  Therefore, the Board concluded that coding as 5258 (semi-lunar cartilage dislocation) was not warranted in this case.  There was also no evidence of sufficient limited ROM based on ROM alone, instability, impairment of the tibia/fibula, or ankylosis of either knee to support higher ratings.  The Board thus determined that the evidence supports a 10% rating for each knee and no higher.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the unfitting left knee condition and a 10% rating for the unfitting right knee condition. 

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB may have relied on the USAPDA pain policy/AR 635-40 for rating the bilateral knee condition and the condition was adjudicated independently of that policy/ instruction by this Board.  In the matter of the bilateral knee condition, the Board unanimously recommends a disability rating as follows: an unfitting left knee condition and an unfitting right knee condition, each rated 10%, both coded 5299-5260 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  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	
Left Knee Chondromalcia Condition	5299-5260	10%	
Right Knee Chondromalacia Condition	5299-5260	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated, 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

JUL 18 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for, AR20160004459 (PD201404096)

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