RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00077
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031212

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2, Tank Systems Mechanic, medically separated for “chronic bilateral knee, due to patellofemoral syndrome” with a disability rating of 0%.  

CI CONTENTION:  His condition continues to worsen.  He was not evaluated for feet, back and face 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 – 20031201	VARD -20040623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Degenerative Arthritis, Bilateral Knees	5010	10%	20040406	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined “chronic bilateral knee pain due to patellofemoral syndrome” under a single Service disability rating, coded analogously to 5099-5003.  Although VASRD §4.71a permits combined ratings of two or more joints, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the “chronic bilateral lower extremity pain” conditions are presented; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began after basic training in November 2002.  The CI was first seen in October 2003, diagnosed with right knee patellofemoral syndrome, and was referred to physical therapy.  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 patellofemoral syndrome” for PEB adjudication.  

The commander’s statement dated 24 October 2003 noted the functional impact on the CI’s daily activities, however, it was nonspecific regarding a unilateral or bilateral condition.  The orthopedic MEB NARSUM examination was dated 27 October 2003, (2 months pre-separation).  The CI reported pain about the knee cap, while maneuvering stairs and squatting, and occasional swelling.  The physical examination showed pain with patellar compression bilaterally (right greater than left), bilateral patellar tendon and medial facet tenderness, full bilateral range of motion, with no evidence of effusion, joint line tenderness, instability, or laxity.  A permanent physical profile dated 4 November 2003 was written for the bilateral knees, limiting running, jumping, marching and rucking, and prohibited only the 2-mile run portion of the fitness test, allowing alternative aerobic testing.  

The MEB examination was completed on 24 October and 7 November 2003.  The CI reported locking, giving way, swelling, and pain with prolonged standing, maneuvering stairs, and after kneeling.  The physical examination showed bilateral tenderness and pain with patellar compression.  

At the VA Compensation and Pension (C&P) examination dated 5 April 2004 (4 months after separation), the CI reported pain and swelling “off and on twice a day,” decreased ability to walk and stand at the end of the day, and no lost time from work.  The physical examination showed a normal gait, normal flexion to 140 degrees bilaterally with pain, and no evidence of meniscal injury or further limitations from fatigue, weakness, lack of endurance or incoordination.  A VA C&P examination dated 6 April 2004 (1 day later) added extension to 0 degrees (normal) bilaterally with no evidence of laxity.  Radiographic evaluations showed degenerative joint disease of the bilateral knees.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the “chronic bilateral knee pain due to patellofemoral syndrome” analogously coded 5099-5003 (degenerative arthritis), citing the USAPDA pain policy.  The VA rated 10% for the “degenerative arthritis, bilateral knee, claimed as patellofemoral syndrome” coded 5010 (), citing radiographic evidence of involvement of two or more major joints…with no limitation of motion and no evidence of incapacitating exacerbations.  

The Board first considered if the bilateral knee pain due to patellofemoral syndrome, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  The knee conditions were profiled as bilateral, implicated in the NARSUM, and both knees were designated as failing to meet retention standards.  Members agreed that the functional limitations in evidence justified the conclusion that the conditions were integral to the CI’s inability to perform the duties of her MOS and that each knee could be reasonably justified as separately unfitting and a separate rating are recommended.  The Board next considered the evidence for a higher rating.  The VASRD §4.71a specifies for 5003 that “satisfactory evidence of painful motion” constitutes limitation of motion; and, that a 10% rating can be granted “for each such major joint or group of minor joints affected by limitation of motion”.  There was documentation of painful motion (bilateral pain with patellar compression, bilateral patellar tendon and medial facet tenderness) and radiographic evidence of degenerative joint disease bilaterally that would warrant a rating of 10% for each knee coded analogously as 5099-5003/5010 (traumatic arthritis) or 5099-5014 (osteomalacia) or 5010-5260 (traumatic arthritis; osteomalacia).  There was no documentation of any compensable limited range of motion of either knee; and no swelling, effusion, edema, instability, or laxity to warrant meniscal coding or a higher rating under 5257 (knee, other impairment of).  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 right knee and 10% for the left knee patellofemoral syndrome conditions.  

BOARD FINDINGS: In the matter of the bilateral patellofemoral syndrome condition, the Board recommends separate disability ratings as follows: 10% for the right knee and 10% for the left knee, both analogously coded 5099-5014 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Patellofemoral Syndrome 	5099-5014	10%	
Left Patellofemoral Syndrome	5099-5014	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150122, 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, AR20160018842 (PD201500077)

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