RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01012
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Combat Trainee, medically separated for “pain in knees (bilateral) due to patellofemoral syndrome and stress fractures,” with a disability rating of 0%.  

CI CONTENTION:  The CI contends his condition continues to worsen and impact his daily activities.  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 - 2020401	VARD - 20020523	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5299-5003	0%	Patellofemoral Syndrome…R/Knee	5299-5021	10%	STR	
			Patellofemoral Syndrome…L/Knee	5299-5021	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

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 shortly after entering training without specific injury.  Knee pain was evident during formation, running, climbing stairs and performing squats.  X-rays were negative.  At the examination dated 15 January 2002, the CI complained of bilateral pain in his legs and knees.  Knees showed full range of motion.  The 31 January follow-up evaluation showed that the bone scan was positive for stress fracture.  Physical examination demonstrated that the CI appeared to have pain with extension of both knees with tenderness to palpation of the tibial plateau.  The CI was diagnosed with stress fractures.  Physical examination by orthopedic consult on 2 March 2002 showed medial tibial plateau tenderness and positive patellofemoral compression, with no laxity or instability.  Bone scan was interpreted as showing marked increase uptake over the medial plateaus of both knees.  There was no surgical indication and pain persisted despite conservative therapy.  The MEB forwarded “severe stress fractures in the knees” and “patellofemoral syndrome in the knees” for PEB adjudication.  

The MEB NARSUM examination on 18 March 2002, a month prior to separation, noted complaints of bilateral knee pain.  The CI complained of pain on extension and pain on the medial aspect of his knees, but denied swelling.  Physical examination showed (bilateral knee) tibial plateau tenderness and patellofemoral compression.  There was no effusion, laxity or instability.  
The commander’s statement indicated the CI could not perform his duties due to “knees prevent him from running, ….”  

The panel directed its attention to its rating recommendation based on the above evidence.  The PEB combined the patellofemoral syndrome and stress fracture of the left knee and patellofemoral syndrome and stress fracture of the right knee conditions as a single unfitting condition coded analogously 5299-5003 and rated 0%, with application of the US Army Physical Disability Agency 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 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 VA rated the patellofemoral syndrome right knee and left knee condition 10% each, coded 5299-5021 (myositis), based on the STRs, citing painful motion of each knee.  

The panel first considered if each knee (patellofemoral syndrome and stress fracture) condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees as a bilateral condition were considered to fail retention standards, both were implicated by the NARSUM and in the commander’s statement, and both were profiled.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee joint over the other.  Since undue speculation would be required to conclude that impairment from either knee joint would not have unacceptably interfered with return to training or duty performance, members agreed that each knee was reasonably justified as separately unfitting.  

The severe stress fracture and patellofemoral syndrome of each knee are considered together for rating each knee IAW VASRD §4.14 (avoidance of pyramiding).  Both knees had similar diagnostic imaging and clinical findings and the rating for each knee is therefore the same.  

Considering rating each knee, there was no range of motion measurements showing limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  Although there was severe stress fracture of each knee (tibial) to support consideration analogous to code 5262 (tibia and fibula, impairment) for knee impairment, there panel majority adjudged that there was insufficient objective evidence of painful motion or functional loss supporting a 10% rating (“slight knee disability,” based on §4.59, §4.40 and §4.45) for either knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee pain condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain (pain in knees due to patellofemoral syndrome and stress fractures) condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification and did not elect to submit a minority opinion.  There were no other conditions within the panel’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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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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,