RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00509
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060316
______________________________________________________________________________

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Avenger Systems Repairer, medically separated for “bilateral knee pain secondary to patella grinding,” with a disability rating of 0%.  

CI CONTENTION:  The CI contends his condition continues to worsen.  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 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 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 - 20060106	VARD	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	0%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 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 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.  The evidence for the right and left knee conditions are presented separately, 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 condition began in January 2005 with an insidious onset.  The MEB forwarded “bilateral knee pain secondary to patella grinding” for PEB adjudication.  An X-ray done 4 May 2005 was normal.  The CI was referred to physical therapy for treatment, but his pain persisted.  The examinations over the next few months were consistently normal for gait, strength, range of motion (ROM), stability, and absence of signs of meniscal (an internal cartilage cushion) irritation.  He did have pain with compression of the kneecap (patella) though.  At the time of evaluation in the orthopedic clinic on 12 September 2005, the CI reported sharp right knee pain since January that worsened with stairs and after long periods of sitting.  He also noted that there was pain after running since advanced infantry training.  There were minimal improvements in the right knee after two weeks of physical therapy (PT).  The physical examination findings were right knee tenderness lateral to the joint line, patellar grind and a ROM limited to 130 degrees bilaterally (it was recorded as normal; however, the VA defines normal as 140 degrees).  The MEB NARSUM examination was dated 7 November 2005, approximately 4 months prior to separation.  The CI reported complaints of bilateral knee pain, right side worse than the left and little improvement after 6 months of PT.  The physical examination of both knees showed patellar tenderness, patella grind, guarding, and minimal joint line tenderness.  The knee was stable and without signs of meniscal irritation.  No comment was made on gait or ROM.  The CI was noted to be able to meet his duty requirements, but he had severe pain afterwards.  It noted that X-rays of each knee were negative for degenerative changes, fractures, or dislocations (implying normal or near normal examinations).  

The CI did not file a claim with the VA therefore no VA Compensation and Pension (C&P) evaluation was performed.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the chronic bilateral knee pain condition 10%, coded 5099 analogous to 5003 (Arthritis, degenerative (hypertrophic or osteoarthritis), citing pain, minimal, occasional.  The Board first considered if the left and right knee pain, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above.  The Board noted that the record showed that the majority of the clinical notes were for the right knee and that the left knee was never evaluated independently of the right.  The clinical notes which addressed both knees consistently noted right > left knee pain.  The Board did not find evidence sufficient to support a recommendation that each knee be found separately unfitting.  Regardless, this did not affect the rating recommendation as discussed below.  The limitation in motion noted by the orthopedist was non-compensable.  There were no signs of instability or meniscal irritation.  Pain was present with activity and painful motion is implied.  This supports a rating no higher than 10% for the bilateral knee pain condition under an analogous code 5003 (degenerative arthritis) IAW VASRD §4.59 (painful motion).  The Board noted that the 10% rating is supported whether the knees are separately unfitting or not and found no route to a higher rating.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends a disability rating of 10% coded 5099-5003, 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Bilateral Knee Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, 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 
XXXXXXXXXXXXXXXXXX, AR20160018734 (PD201500509)

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