RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04298
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, M1 Armor Crewman, medically separated for “bilateral knee pain…” with a disability rating of 0%.

CI CONTENTION:  The CI contended “lung problems, PTSD, knees and shoulders.”  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 – 20050126 	VARD - 20051123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain Secondary to RPS	5099-5003	0%	RPS, Right Knee	5257	0%	20050719	
			RPS, Lt Knee				
Residual Right Shoulder Pain	Not Unfitting	Residuals, s/p Right Shoulder Arthroscopy	5201			
Recurrent Reactive Airway Disease		RAD w/Chronic Cough		10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain Secondary to Retropatellar Pain Syndrome.  The PEB combined the right and left knee conditions as a single unfitting condition coded analogously to 5003 (degenerative arthritis) and rated 0%.  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.  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.  The evidence for the right and left knee conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s retropatellar pain syndrome was diagnosed in December 2002.  Bilateral knee X-rays were negative and bone scan showed increased uptake of the right knee consistent with degenerative changes.  The CI was given a permanent L2 profile for an alternate Physical Fitness Test and continued his career.  Following this the CI was deployed and completed the deployment with his unit.  The knees were re-evaluated in June 2004.  Bilateral knee X-rays to evaluate the patella were negative.  Right knee magnetic resonance imaging in September 2004 was negative.  Treatment notes in the record indicated the CI was evaluated primarily for reported right knee pain.  An MOS Medical Retention Board (MMRB) in November 2004 noted profile limitations of “no forced running, repetitive jumping, squatting or deep knee bends due to chronic bilateral knee pain” and recommended the CI be referred to the MEB/PEB system.  The MEB forwarded “Bilateral knees: Chronic retropatellar pain syndrome” for PEB adjudication.  The permanent profile dated 27 September 2004 listed chronic profile knee pain with physical limitations that applied equally to both knees.  The commander’s statement indicated the CI’s duty performance was impaired due to chronic bilateral knee pain resulting in the previously noted physical limitations.

At the MEB NARSUM examination on 11 January 2005, 3 months prior to separation, the CI reported constant bilateral knee pain aggravated by weight bearing and impact activities, as well as squatting, kneeling, crawling.  He reported he could not stand longer than 30 minutes, but could walk on a treadmill for up to an hour.  The physical examination showed right knee medial joint line tenderness to palpation (TTP).  Right knee range of motion was 0 degrees extension (normal 0 degrees) and 130 degrees flexion (normal 140 degrees).  There was left knee TTP of the lateral joint line and a positive patellar grind.  Left knee range of motion was also 0 degrees extension and 130 degrees flexion. There was no swelling, effusion, instability or evidence of meniscal pathology of either knee.  

At the 19 July 2005 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported he injured both knees during deployment when he climbed off a tank and into a hole, twisting both knees.  He reported bilateral knee pain since then, right greater than left.  He graded the right knee pain 6/10 and the left 4/10.  The CI denied instability, but wore a right knee brace occasionally in anticipation of activity.  The CI reported he could not run, he could walk 1 mile, he could sit comfortably for 20 minutes, and he could climb stairs with more difficulty going up stairs than down.  The physical examination showed a normal gait.  The CI was able to arise from a chair without difficulty.  He was not wearing any braces or using a cane or crutch for ambulation.  The examination was reported for the bilateral knees.  Strength, sensation, and reflexes were normal.  There was no swelling, crepitus, TTP, or pain with patellar grind.  There was no evidence of instability or meniscal pathology.  The CI could squat to 75 degrees repetitively, limited by pain, and ROM of both knees was full (full extension to 140 degrees flexion).  There was no additional limitation of ROM of either knee with repetition.  Right and Left knee X-rays were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 as noted above, citing loss of joint motion with normal imaging.  The VA rated the right and left knee each 0%, both coded 5257 (knee impairment), based on the VA C&P examination 4 months after separation.  

The Board first considered if both the right and left knees, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards, both were implicated by the NARSUM and in the commander’s statement, and both were profiled.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the each of the bundled knee conditions was reasonably considered separately unfitting. Board then considered its rating recommendation for both the unfitting knee conditions at the time of separation.  

The clinical features of both knees were nearly the same at the MEB NARSUM examination and identical at the VA C&P examination and therefore, the ratings for both knees were considered together.  The bilateral retropatellar pain syndrome (RPPS) diagnosis with normal imaging of both knees supported a single 5003 coding for “2 or more major joints” without significant ROM limitations or painful motion; thus there is VASRD §4.71a latitude for a bilateral rating.  The Board considered if the evidence warranted separate 10% rating for both knees based on functional loss considerations.  However, in the STR, the CI primarily reported right knee pain.  Both the MEB NARSUM and VA C&P examinations were minimally abnormal, with tenderness of both knees noted at the MEB NARSUM, and no abnormality noted at the VA C&P examination, except for minimal limitation due to pain when squatting beyond 75 degrees.  Members agreed, therefore, that the evidence did not reach the threshold for separate 10% ratings based on painful motion with functional loss (based on §4.59, §4.40 and §4.45).  

There likewise 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).  Thus, although the Board recommends that each knee was unfitting at separation, the rating recommendation is 10% for the bilateral RRPS syndrome, coded 5099-5003.  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 secondary to RPPS condition, coded 5099-5003  

Contended PEB Conditions:  Residual Right Shoulder Pain and Recurrent Reactive Airway Disease.
The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the two contended conditions was profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for 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 and an unfitting left knee condition, coded 5099-5003 and rated 10% as a bilateral joint condition, IAW VASRD §4.71a.  In the matter of the contended “residual right shoulder pain” and recurrent reactive airway disease conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Bilateral Knee Pain Secondary to Retropatellar Pain Syndrome	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140103, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160018353 (PD201404298)

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.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA