RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01006
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Armament/Electrical/Avionics System Repairer, medically separated for “chronic pain, bilateral knees,” with a disability rating of 10%.

CI CONTENTION:  “Review 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 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 - 20050826	VARD - 20051213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Bilateral Knees	5099-5003	10%	Patellofemoral Pain Syndrome, Left Knee	5299-5260	10%	STR	
			Patellofemoral Pain Syndrome, Right Knee	5299-5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pain, Bilateral Knees.  The PEB rated the bilateral patellofemoral condition as a single unfitting condition analogously coded 5003 (arthritis, degenerative), rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 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.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral patellofemoral pain syndrome began in June 2002.  In October 2002 the CI was diagnosed with patellar tendonitis.  A bone scan in July 2004 was reported as mild stress changes consistent with shin splints, right greater than left.  A magnetic resonance imaging of the right knee in April 2005 noted degenerative changes of the substance of the menisci with no obvious tear.  

At the 2 May 2005 orthopedics clinic appointment, the CI complained of right greater than left knee pain without significant improvement of symptoms despite profiling, medication and physical therapy.  There was no surgical indication and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “patellofemoral pain syndrome and patellar tendonitis” for PEB adjudication.  

The MEB NARSUM examination on 13 June 2005, 5 months prior to separation, noted the CI complained of pain despite treatment.  Physical examination showed crepitus on patellar compression and extension.  There was a positive patellar apprehension examination mainly on the right.  Mild joint effusion and peripatellar edema on several occasions during clinic visits was noted.  Range of motion (ROM) conducted by physical therapy on 10 August 2005 demonstrated left knee ROM was flexion of 115 degrees (normal 140) and extension 0/-5 degrees (normal 0).  The right knee ROM showed flexion of 125 degrees and extension of 0/-5 degrees.  Both knees were limited by pain.  

The CI did not have a VA Compensation and Pension (C&P) evaluation in evidence.  The VA used the STR to determine the rating.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5099-5003 (arthritis, degenerative), citing application of the USAPDA pain policy.  The VA rated each knee 10%, both coded 5299-5260 (leg, limitation of flexion), based on the STR, citing limited painful ROM and crepitus.  The Board first considered if the each knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were profiled and limitations included no running, jumping, ruck marching or deep knee exercises causing excessive knee flexion.  According to the commander’s statement dated 8 June 2005, the CI’s physical impairments prevented him from fulfilling the requirements of his MOS.  

Board members agreed that the evidence reasonably justified that the functional limitations of each knee contributed to the CI’s inability to perform his military duties and accordingly separate disability ratings are recommended.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee.  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 or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a route to a higher rating under any applicable code for either knee, and no grounds for additional rating based on the presence of instability.  After due deliberation, and considering all of the evidence, the Board recommended a disability rating of 10% for the right knee condition and 10% for the left knee condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left 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	
Right Knee	5099-5003	10%	
Left Knee	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150606, w/attachments
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

06 MAR 2017

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000874 (PD201501006)

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