RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00357
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3 Health Care Specialist, medically separated for “bilateral chondromalacia” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20061213	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Chondromalacia	5099-5003	0%	 	 	 	 	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Bilateral Chondromalacia.  The PEB combined the left and right knee conditions as a single unfitting condition coded 5099-5003 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 left and right knee conditions are presented together, 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 bilateral knee conditions began in 2005 during basic training when she fell out of a large tactical vehicle.  A bone scan, dated 6 February 2006, showed mild stress changes in both knees.  At the Troop Medical Clinic appointment on 8 May 2006, the examination showed tenderness to palpation of the tendons of both kneecaps.  The knee range of motion (ROM) was normal and pain free.  She was thought to have bilateral patellar (kneecap) tendonitis.  X-rays on 3 August 2006 were normal.  The Physical Profile dated 10 October 2006 lists only left knee pain and is silent regarding the right knee.  The Physical Therapy ROM study on 23 October 2006, 3 months prior to separation, showed right knee flexion of 130 degrees with pain (normal 140); right knee extension of 0 degrees with pain (normal 0); left knee flexion of 135 degrees with pain; and left knee extension of 0 degrees with pain.  The commander’s statement dated 24 October 2006, indicated that the CI was hindered by the profile restrictions.  The commander said that the CI sustained a knee injury, but never specifically stated if one or both knees affected the CI’s duty performance.  Despite treatment the CI was not able to meet the physical requirements of her military specialty and was referred for MEB.  The MEB forwarded “patellar chondromalacia” for PEB adjudication, but did not indicate if this diagnosis was for the left knee only or for both knees.  The MEB examination on 9 November 2006, 2 months prior to separation, showed that the CI had pain to palpation of the patellar tendons.  There were no other pertinent findings for the knees.  

The MEB NARSUM dated 21 November 2006, 2 months prior to separation, noted constant pain aggravated with exertion.  On examination there was pain to palpation of both patellar tendons.  An MRI of the left knee, dated 1 December 2006, showed mild degenerative changes and a small effusion.  At the orthopedic clinic visit on 11 December 2006, 1 month prior to separation, the examiner recorded that the visit was a follow-up for a trial of duty and physical fitness test that included the walk as the cardiovascular event because of a history of left knee patellofemoral pain syndrome.  The CI passed the fitness test, but hurt so much after that she could not perform her combat medic duties due to pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (analogous to degenerative arthritis).  There was no VA evaluation in evidence.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion for either knee (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity in either knee (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions in either knee (5258) or history of surgery to remove a meniscus (5259) to support a rating of either knee under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia of either knee to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The bone scan did show bilateral stress related changes.  The Board considered if the knees were separately unfitting and noted that the left knee was clearly more symptomatic.  However, there was no route to a compensable rating other than using the code 5003.  It supports the 10% rating adjudicated by the PEB based on evidence of painful motion in both knees with functional loss (based on §4.59, §4.40 and §4.45).  The Board considered if the knees were separately unfitting, but noted that this is rendered moot as severing the knees for rating purposes provides no advantage to the CI.  
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral chondromalacia condition.  

BOARD FINDINGS:  In the matter of the bilateral chondromalacia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150527, with attachments
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

19 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018694 (PD201500357)

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, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA