RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00766
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080520

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Patriot Launching Station Enhanced Operator/Maintainer Trainee, medically separated for “arthritis, degenerative, both knees” and “chronic epididymo-orchitis,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “Pain in area determined have worsened making it hard to stand for very long periods at a time.  Which makes it harder to keep a job.”  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 - 20080506	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis, Degenerative, Both Knees	5003	10%	No VA Exam in Evidence	
Chronic Epididymo-Orchitis	7525	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Arthritis, Degenerative, both Knees.  The PEB combined the bilateral knee degenerative arthritis conditions as a single unfitting condition coded 5003 and rated 10%.  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 or implied adjudication that each condition was separately unfitting.  The panel 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 panel’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 panel 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 panel 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 bilateral knee conditions are presented, 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 October 2007, right greater than left, after a twisting injury of the right knee.  Surgery was not indicated, treatment did not result in improvement sufficient to allow unrestricted duty and the CI was referred for an MEB.  The MEB forwarded “chronic bilateral knee pain” for PEB adjudication.  

At the 2 April 2008 MEB examination (recorded on DD Forms 2807 and 2808), 2 months prior to separation, the CI reported bilateral knee pain and swelling.  Physical examination of the lower extremities was checked “normal.”  The 10 April 2008 profile was written for “chronic bilateral knee pain,” prohibited the 2-mile run, and did not approve any alternate aerobic events.  The 17 April 2008 commander’s statement did not specifically address any issues pertaining to the knees.  At the 16 April 2008 MEB NARSUM examination, one month prior to separation, the CI reported right knee swelling with running, and pain that worsened while standing, walking, jumping, and pivoting.  The physical examination showed normal motion without pain, and no evidence of laxity or tenderness on ambulation.  

There was no VA Compensation and Pension (C&P) examination in evidence for review.  

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Knee ROM
(Degrees)	Clinic ~6 Mos. Pre-Sep
(20071123) p.104	Ortho ~2 Mos. Pre-Sep
(20080331) p.196	PT/MEB ~1 Mo. Pre-Sep
(20080416) p.33	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	Full ROM	Within Normal Limits (WNL)	Normal Motion	140	140	
Extension (0 Normal)				0	0	
Comment		TTP @ MTP			No Pain/FROM on repetition	
§4.71a Rating	0%	0-10%	0%	0%	0%	0%	

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 10% for the bilateral knee condition, coded 5003 (arthritis, degenerative), citing a rating for “2 major joints with radiographic evidence and no loss of motion.”  The panel first considered whether each knee condition remained separately unfitting, having been de-coupled from the combined PEB adjudication.  The bilateral knees were profiled.  They were both implicated by the NARSUM examiner, and forwarded by the MEB.  Panel members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties and accordingly a separate disability ratings can be recommended.  

The panel next considered the rating.  As noted above, there were no distinctions with regards to clinical features or fitness considerations between the right and left knees.  Although the CI was undergoing an MEB for “bilateral knee pain,” there was no documentation of painful motion, or a painful gait.  There was evidence of a right tibial plateau stress fracture, however, there was no radiographic evidence of arthritis.  Members debated if application of §4.40 (functional loss) or §4.59 (painful motion) justified separate 10% ratings.  In this case, there was no documentation of limitations of motion and no documentation of painful motion, therefore, no support for a higher rating using other rating schemes.  The panel concluded that the evidence did not provide sufficient grounds for recommending separate knee disability ratings.  A bilateral diagnosis supports a single 5003 based rating for “2 or more major joints” without evidence of compensable limitations or painful motion.  Panel members agreed that there was no support for a bilateral rating higher than the 10% rating adjudicated by the PEB. 

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 for the bilateral knee pain condition.  

Chronic Epididymo-Orchitis.  According to the STR and the MEB NARSUM, the CI’s epididymo-orchitis condition began in January 2008 with no particular traumatic event.  There was no STR documentation of hematuria (blood in the urine), urinary frequency, incontinence or painful urination.  Testicular ultrasound in January 2008 and 3 urinalyses (January, February, and April 2008) documented no specific abnormalities (no evidence of infection or hematuria).  One course of antibiotics (empiric therapy) was given for acute epididymitis in March 2008, however the symptoms continued.  Surgery was not indicated and treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic testicular pain” for PEB adjudication.  

At the 2 April 2008 MEB examination (recorded on DD Forms 2807 and 2808), 2 months prior to separation, the CI reported testicular pain and swelling with difficulty urinating.  The physical examination showed tenderness on testicular palpation.  The 16 April 2008 MEB NARSUM examination, 1 month prior to separation, noted complaints of pain related to physical activity (running, climbing, and marching) with no other genital or urinary symptoms.  The physical examination showed tenderness and swelling with no evidence of spermatocele.  

There was no VA Compensation and Pension (C&P) evaluation in evidence for review.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the chronic epididymo-orchitis condition, coded 7525 (epididymo-orchitis, chronic), citing pain and chronic swelling.  The panel considered the evidence for rating.  VASRD code 7525 (epididymo-orchitis, chronic) specifies rating as a urinary tract infection.  There was no evidence of urinary frequency, obstructed voiding, or voicing dysfunction.  There was no evidence of long term drug therapy or frequent hospitalizations (greater than two times per year), or continuous intensive management for this condition for a higher rating.  The panel considered analogous code 7120 (varicose veins) but there was no evidence of persistent edema or changes in the skin associated with chronic varicosities to support a higher rating.  The panel agreed that VASRD §4.124 (neuralgia) and §4.123 (neuritis) codes under the ilioinguinal nerve could be used as analogous codes given the testicular symptoms located at the groin area.  Analogous coding using 8730 (neuralgia) permits a maximum rating of 0% for “moderate incomplete paralysis.”  Analogous coding using 8630 (neuritis) stipulates a maximum 0% rating of ‘moderate’ when not characterized by organic changes (such as inflammation or non-injury).  Panel members agreed that there was no paralysis and no evidence of organic changes (for a ‘severe’ rating level of 10%) in support of a higher rating for this condition.  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 for the epididymo-orchitis condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the epididymo-orchitis condition and IAW VASRD §4.115b, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’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 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006562, 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