RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00997
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Engineer, medically separated for “chronic bilateral anterior knee pain…” with a disability rating of 10%.

CI CONTENTION:  The CI requested consideration of all conditions. 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 upon a 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 - 20030918	VARD - 20040212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Anterior Knee Pain	5099-5003	10%	Degenerative Joint Disease of Right Shoulder, Left Knee, and Right Knee	5003	10%	20030429	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Anterior Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain began in November 1992 with running and was originally diagnosed as retropatellar pain syndrome, which over time slowly and progressively worsened.  In June 2001 she was noted to have bilateral genu valgum (knock knees) and tenderness to palpation of the medial undersides of the patellae.   X-ray studies for each knee were “essentially unremarkable except [for] a minimal amount of arthrosis.”  Orthopedic evaluation in May 2002 revealed range of motion (ROM) flexion 0 to 135 degrees (normal 140) bilaterally and a positive patellar grind and 1+ Lachman’s test with an endpoint (normal to mild laxity) bilaterally.  Despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDS) and physical therapy, the bilateral knee conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “bilateral anterior knee pain” for PEB adjudication.  

The ROM evaluations 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)	VA C&P ~7 Mos. Pre-Sep	MEB ~3 Mos. Pre-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	140	140	140	140	
Extension (0 Normal)	0 	0	10 Hyper	10 Hyper	
Comment			Positive patellar grind test; 3/4 quadrant mobility of both patellae; moderate tenderness over both lateral patellar facets	
§4.71a Rating	0% (VA 10%)	PEB 10%	

At the 29 April 2003 VA Compensation and Pension (C&P) examination, 7 months prior to separation, the CI reported a “constant ache in both knees with bending and squatting.  Her knees [got] stiff with sitting.” She claimed that “at certain points she almost [lost] her balance because her knees [bothered] her.  The pain [was] located under the right knee cap or deep within the knee joints bilaterally.  During flare-ups she [couldn’t] bend the knees well or squat.”  Physical examination showed normal gait and ROM for both knees as indicated in the chart above.  Her knees were “not additionally limited by pain, fatigue, weakness, lack of endurance [or] incoordination.”  Bilateral examination tests for meniscal pathology or ligamentous instability were negative and there was “no evidence of recurrent subluxation, locking pain, joint effusion or crepitus” in either knee.   

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 4 June 2003, 5 months prior to separation, the CI reported that she lost “her balance in both knees and sometimes they gave out.”  Physical examination for her lower extremities were normal.  At the MEB NARSUM, 18 August 2003, 3 months prior to separation, the CI reported “constant swelling with exacerbation secondary to activities such as climbing on vehicles as well as sitting or standing for long periods or any type of running or long walks.  She had quadriceps inhibition type giving way symptoms as well as occasional subjective locking.”  Physical examination showed normal ROM with 10 degrees of hyperextension bilaterally as indicated in the chart above.  She had positive bilateral patellar grind tests, “3/4 quadrant mobility of both patellae,” and “moderate tenderness to palpation over both lateral patellar facets.”  Examination tests for ligamentous instability were negative.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded analogously to 5003 (degenerative arthritis), citing slight and frequent pain IAW the USAPDA pain policy (AR 635-40).  The VA rated the bilateral knee condition (along with the CI’s right shoulder condition) 10%, coded 5003, citing involvement of multiple joints with no limited or painful motion.  There was no evidence for either knee of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Likewise, there was no limitation of motion for either knee which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261), no history for either knee 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 for either knee, and no fracture, non-union, or malunion of the femur or tibia of either leg to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, the CI had bilateral knee involvement of patellar hypermobility and bilateral knee hyperextension.  Therefore, use of code 5257 for recurrent slight subluxation or lateral instability for each patella is not unreasonable.  Furthermore, bilateral knee hyperextension raises consideration of genu recurvatum (5263) (where the knee bends backward and excessive extension occurs in the tibiofemoral joint), which was acquired and was associated with weakness and insecurity in weight bearing based on quadriceps inhibition symptoms.  However, the CI’s reporting was subjective rather than objective, although there was bilateral tenderness of the knees and bilateral crepitus.  Board members noted that both the PEB and the VA bundled the bilateral knee condition and assigned one rating for the bundled condition, while the VA had a third condition bundled in with the bilateral knee condition as well.  Therefore, based upon the evidence as well as the type of work the CI performed in her military occupational specialty, Board members determined that an individual rating for each knee at 10% for each knee using code 5257 or a 10% rating for each knee using an analogous code 5299-5263 was appropriate.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the Board recommends a disability rating of 10%, coded 5299-5263 for the right knee pain condition and a disability rating of 10%, coded 5299-5263 for the left knee pain condition 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	
Right Knee Pain	5299- 5263	10%	
Left Knee Pain	5299-5263	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170000754   (PD201500997)

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 20% 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