RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2015-00495
BRANCH OF SERVICE:  Army	SEPARATIONDATE:  20030516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Carpentry and Masonry Specialist, medically separated for bilateral knee pain with a disability rating of 20%.  

CI CONTENTION:  Please consider all conditions.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20030310	VARD - 20040124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain w/ Right Meniscal Tears 	5010	20%	Surgical Residuals, Right Knee	5299-5257	0%	20030930	
			Left Knee Condition	5257	NSC	20030930	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a 1999 onset of bilateral knee pain diagnosed as recurrent patellofemoral pain syndrome, without a specific history of injury.  The CI was diagnosed with a torn meniscus of the right knee necessitating an arthroscopic repair in February 2001.  With recurrent pain, magnetic resonance imaging (MRI) demonstrated a new meniscal tear in July 2001 that was unchanged on a repeat MRI that November.  Both studies confirmed that all ligaments were intact.  The CI underwent a second arthroscopic meniscectomy of the right knee in May 2002, 12 months before separation.  
The CI subsequently presented with an acute atraumatic onset of left knee pain in November 2002, 6 months before separation and an MRI demonstrated chondromalacia patella and a meniscal tear.  There was no surgical intervention for the left knee.

There was ample STR documentation of a normal gait and ligamental stability of both knees, with no contrary evidence.  An orthopedic entry, quoted in the NARSUM and MEB diagnosis, documented “recurrent effusions”, but this was not corroborated by the physical examinations or imaging reports in evidence.  Several STR clinical entries for the right and left knees noted the absence of effusion; and, with the exception of one examiner who recorded a “1+ effusion” of the right knee, there was no documentation of an effusion by examination.  There was no STR documentation of any complaint of locking, and there was confirmation of the absence of impingement by physical examination for each knee.  With the exception of post-operative notes for the right knee, there was ample STR documentation of grossly normal range of motion (ROM) for both knees, and no entries that indicated significantly limited ROM.  This evidence was contrary however, to the MEB’s DD Form 2808 physical examination (contemporary with the NARSUM) that recorded “marked decreased ROM of knees due to pain,” and to the NARSUM evidence.  Additional conservative treatment did not result in sufficient improvement to allow unrestricted duty and, the CI was referred for an MEB which in turn forwarded “chronic bilateral refractory to conservative and medical measures bilaterally and surgical treatment on the right” and “chondromalacia or osteochondritis desiccans, severe, manifested by frequent joint effusion” to the PEB.  

The NARSUM examination on 21 January 2003, 4 months before separation, documented nonspecific bilateral knee pain that prohibited running and interfered with prolonged sitting or standing in one position, climbing, squatting, and kneeling.  There was no mention of subjective instability or locking.  The physical examination recorded bilateral medial tenderness, “trace effusions,” 4-plane stability to stress testing, and no mechanical impingement.  Measured ROM for the right knee was flexion to 90 degrees (normal 140) and extension to minus 5 degrees (normal 0) and left knee flexion to 85 degrees and extension to minus 5 degrees, specifying “significant pain at end points” for each knee.

A VA Compensation and Pension (C&P) examination on 30 September 2003, 4 months after separation, documented nonspecific bilateral knee pain with “swelling and occasional locking” that interfered with prolonged standing and squatting.  The physical examination recorded a normal gait without a knee brace, “vague” medial tenderness, the absence of effusion, 4-plane stability to stress testing, and negative signs of impingement bilaterally.  Bilateral ROM was characterized as “full.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s bilateral 20% rating under code 5010 (traumatic arthritis) did not specify separate 10% ratings or elaborate a rationale, although the absence of instability was noted.  The VA‘s 0% rating for the right knee under code 5299-5257 (analogous to knee, other impairment) stated that the C&P examination “fails to note significant residual disability;” and, service-connection for the left knee was denied, opining “no chronic left knee condition is identified.”  The panel first noted that the PEB’s bilateral code and rating was not technically in compliance with VASRD §4.71a, since code 5010 defaults to rating criteria of 5003 (degenerative arthritis) and, the latter confers only a 10% rating for “2 or more major joints.”  Members agreed that it was reasonable to treat the PEB adjudication as separate 10% ratings for each knee with bilateral factor and to individually assess each knee for the possibility of a rating higher than 10%.  There was no ROM limitation or fracture with non-union or malunion for either knee that would support a rating higher than 10% under alternate codes.  A 20% rating under code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) was considered for each knee.  Panel members agreed however, that this could not be reasonably justified for either knee.  Although there was some evidence for effusions, this was not sufficiently corroborated as a common finding; and, there was even less corroboration for the requisite locking.  There was no evidence for instability of either knee to support additional rating on that basis.  Members therefore concluded that there was no reasonable justification for recommending a rating higher than 10% for either knee.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the bilateral knee condition.

PANEL FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150601, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006491, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       
						      					
Enclosure