RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00970
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060307

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Aircraft Powertrain Repairer Trainee, medically separated for “bilateral knee pain” and “bilateral leg pain,” rated 0% and 0%, respectively, with a combine disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  The 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 - 20060217	VARD - 20070206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Left Knee Condition	5099-5003	NSC 	20061222	
			Right Knee Condition	5099-5003	NSC 	20061222	
Bilateral Leg Pain	5022	0%	Left Shin Splints	5299-5262	NSC 	20061222	
			Right Shin Splints	5299-5262	NSC 	20061222	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:

Bilateral Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition began in November 2005 without any apparent history of trauma or injury.  The MEB forwarded “bilateral patellofemoral syndrome” for PEB adjudication.  The MEB NARSUM examination on 1 December 2005, 4 months prior to separation, noted complaints of bilateral knee and leg pain with increased activities such as running and squatting.  Physical examination by an orthopedic specialist showed “full range of motion of both his knees and ankles.”  Measured knee range of motion (ROM) was 0-130 degrees (normal 0-140) with no crepitus for each knee.  There was mild diffuse anterior tenderness to palpation over both knees.  Both knees were stable with no laxity or effusions.  The examiner stated that “films of both his knees and tibiae are relatively normal with some possible mild increased cortical thickening in both of his distal tibiae indicative of some stress reaction in this area.”  Source radiology reports were not in evidence.  The diagnosis was bilateral patellofemoral syndrome.

At the 22 December 2006 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported bilateral knee pain, weakness, buckling, and swelling with walking or activity.  X-rays of the knees were negative.  Physical examination showed normal knee examinations for each knee with no laxity or instability.  ROM for each knee was normal without pain or other limitations on repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee pain condition 0%, analogously coded 5003 (degenerative arthritis), citing U.S Army Physical Disability Agency (USAPDA) Pain Policy as minimal and intermittent pain.  The VA denied service connection for each knee condition, based on the C&P examination 9 months after separation, citing knee tenderness and crepitus with normal X-rays and no diagnosis or pathology.  The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5003 and rated 0% with application of the USAPDA pain policy and AR 635-40 B24.f.; and also combined the left and right leg pain conditions coded 5022 (periostitis) 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, and that additionally the tibia conditions may impact the knee conditions.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under single ratings 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.

Neither knee had limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur to support consideration under the respective 5255 code for knee impairment.  Any aspect of the bilateral tibial stress reaction on the bilateral knees will be discussed under the bilateral leg pain condition below.  There was insufficient evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) for either knee.  There was insufficient evidence of arthritis or degenerative changes in either knee to warrant a 10% rating analogous to 5003 for two or more joints.  As neither knee separately or together would warrant any combined rating greater than 0%, the fitness of either knee separately was moot.  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.

Bilateral Leg Pain.  According to STRs and the MEB NARSUM, the CI’s bilateral leg pain condition began in November 2005 without any apparent history of trauma or injury.  The MEB forwarded “bilateral shin splints” for PEB adjudication.  The MEB NARSUM examination on 1 December 2005, 4 months prior to separation, noted complaints of bilateral knee and leg pain with increased activities such as running and squatting.  As stated above diagnostic imaging showed “some possible mild increased cortical thickening in both of his distal tibiae indicative of some stress reaction in this area.”  Physical examination by an orthopedic specialist showed mild anterior tibial tenderness to palpation from approximately the mid to distal one-third of the anterior surface of the tibia bilaterally.  The lower leg compartments were soft bilaterally and there was no neurovascular deficit bilaterally.  The diagnosis was bilateral shin splints or medial tibial stress syndromes in both tibiae that may lead to eventual tibial stress fractures if activities are increased.”

At the 22 December 2006 C&P evaluation, performed 9 months after separation, the CI reported pain in both shins that traveled around the legs with limited standing or walking for long periods.  X-rays of the left and right tibia-fibula were negative.  Physical examination showed normal findings on examination of both the left and right tibia and fibula.  ROM of the bilateral ankles were normal without painful motion or additional limitation by pain, fatigue, weakness, lack of endurance or .incoordination after repetitive use.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral leg pain condition 0%, coded 5022 (periostitis), citing tibial tenderness, radiographs showing stress reaction, and “rated as there are no joints involved.”  The VA denied service connection for each shin (lower leg) condition, based on the C&P examination 9 months after separation, citing normal examination and normal X-rays of the tibia and fibula with no diagnosis or pathology.  The Board adjudged that the MEB NARSUM examination was closest to separation and best depicted the CI’s disability picture with the more remote VA examination indicating post-separation improvement.  There was little clinical distinction between the left leg and right leg conditions and the Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the bundled left and right leg pain conditions were each reasonably considered separately unfitting.  The Board then considered its rating recommendation for the unfitting left and right leg pain conditions at the time of separation.  

Although there was no frank fracture, non-union, or malunion of the tibia, there was a tibial stress reaction on each tibia and the Board considered analogous coding under 5262 (tibia and fibula, impairment of).  Given the evidence of the record, the Board consensus was that there was sufficient evidence of “slight knee or ankle disability” on each leg to warrant a 10% rating for each lower leg.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends an unfitting right leg pain condition with a disability rating of 10%, and an unfitting left leg pain condition with a disability rating of 10%, each coded 5022-5262.

BOARD FINDINGS:  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral leg pain condition, the Board majority recommends an unfitting right leg pain condition with a disability rating of 10%, and an unfitting left leg pain condition with a disability rating of 10%; each coded 5022-5262 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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	
Bilateral Knee Pain	5099-5003	0%	
Left Leg Pain	5022-5262	10%	
Right Leg Pain	5022-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005392 , XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure