RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00823
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Automated Logistics Supply Specialist, medically separated for “bilateral knee pain,” with a  disability rating of 10%.

CI CONTENTION:  The CI contends her rating is too low.  

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 – 20061018	VARD - 20070827	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Bilateral Knee Condition	5099-5260	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5003 and rated 10%.  This 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 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 rating in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in November 2005 after she fell from a confidence course wall, landing on her feet, and striking her left knee against the wall.  In December 2005, the CI’s injury was treated with Robaxin (a muscle relaxant), physical therapy, and a temporary profile was issued.  The CI re-injured her left knee when it gave out while running resulting in her falling on her right knee.  At a 10 May 2006 clinic encounter, the CI complained of bilateral knee pain that was not resolving.  The bilateral knee examination revealed joint line tenderness and patellae crepitus (grating sensation or sound).  There was no induration (loss of elasticity and pliability), erythema (redness), warmth, or laxity.  Bilateral knee range of motion (ROM) was full.  The anterior/posterior drawer (assesses anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]) and McMurray (assesses menisci) tests were negative.  Bilateral knee X-rays on 10 May 2006 were normal.  At the time of the orthopedic clinic appointment on 4 August 2006, the CI reported bilateral peripatellar knee pain with difficulty running, marching, standing, and sitting.  The CI indicated she was using anti-inflammatory medication.  On examination, the knees were stable, lateral retinaculae were tight, and pain was noted on palpation and flexion of the left knee.  Despite treatment, the bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “bilateral knee pain” for PEB adjudication.  

At the 5 September 2006 MEB examination (DD Forms 2807 and 2808), 4 months prior to separation, the CI reported constant knee pain aggravated by bending, walking, running, and carrying anything, with no relieving factors.  Intermittent bilateral edema (excess tissue fluid swelling) with standing long periods (1-1 ½ hours) was reported.  Physical examination showed no edema or erythema. There was anterior pain in the left and right knees with flexion, and tenderness.  The MEB NARSUM examination, 3 days later, noted complaints of constant pain of the left knee that increased on standing, sitting for 10 minutes, walking with tennis shoes for 10-15 minutes, and immediate pain walking in boots, crawling, bending, kneeling, and lifting.  The CI detailed that the pain woke her up at night.  The right knee, used to compensate for the left knee pain, resulted in the right knee becoming painful.  The CI reported being unable to perform her duties with some impact to her social activities.  The left knee examination revealed crepitus and posterior, infrapatellar, and superficial lateral patella tenderness.  There was pain with walking on toes, squatting, varus/valgus stress, and hip and knee flexion.  The right knee examination revealed medial, lateral joint line, infrapatellar, and superomedial patella tenderness.  There was pain with squatting.  A goniometer measured bilateral ROM as flexion of 127 (140 normal) and extension of 0 (0) degrees.  The 12 September 2006 orthopedic surgery bilateral knee examination revealed no evidence of retropatellar changes, meniscal pathology, or internal ligament derangement.  Bilateral active ROM was flexion of 127 (140) and extension of 0 (0) degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the left and right knee conditions remain separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing slight/constant bilateral knee pain rated IAW US Army Physical Disability Agency pain policy.  The VA denied service connection for the bilateral knee under an analogous 5260 code (leg, limitation of flexion) based on the STR.  The VA noted the CI was a “no show” for the scheduled VA C&P examination and cited absence of a current disability.  The ROM values in the proximate examinations did not support a minimum rating under the limitation of knee flexion (5260) and extension (5261) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 knee condition.  

BOARD FINDINGS:  In the matter of the bilateral knee 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 20150603, 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, AR20170001042  (PD201500823)

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