RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01075
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071219

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated for “bilateral knee pain,” with a disability rating of 0%.  

CI CONTENTION:  A review of all conditions is requested. His 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 – 20071015	VARD - 20080626	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain	5099-5003	0%	Chronic…Right Knee Pain…	5010-5260	NSC	STR	
High Frequency Hearing Loss	Not Unfitting	Right Ear Hearing Loss	6100	NSC	20080221	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  The PEB combined the right and left knee conditions as a single unfitting condition coded analogously to 5003 and rated 0%.  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.  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.  

Bilateral Patellofemoral Pain.  
According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in high school when he hyper-extended his right knee. His July 2005 entrance physical did not note this and the knees did not bother him through basic training. In May 2006, the right knee became worse while running with a 45-50 pound ruck on uneven grade and surface.  X-rays showed right knee effusion.  Diagnostic imaging (MRI) in June 2006 showed a small ganglion or cyst without meniscal tear, and was otherwise normal.  Clinical records focused on right knee pain with resolution of the effusion, but no relief of right knee pain despite medication, use of a brace, and injections.  Left knee, meaning bilateral knee, evaluations began in January 2007.  Despite treatment, the knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “patellofemoral syndrome” for PEB adjudication.  

The MEB NARSUM examination on 22 August 2007, 4 months prior to separation, noted complaints of chronic right knee pain with weakness, stiffness and occasional swelling, instability or giving way when climbing stairs, falling once a week, and use of a knee brace.  Prior clinical exams had shown normal gait with no painful motion and crepitus over the patella with range of motion (ROM) testing.  Physical examination of the bilateral knees showed no deformities, no pain on knee movement, no muscle weakness, no neurovascular deficit, negative patellar apprehension test, and negative Lachman’s (stability) test.  There was medial tenderness on palpation of the right knee.  ROM testing showed mechanical limitations with flexion to 132 degrees (normal 140) and extension to 0 degrees (normal) for each knee.  There was no VA Compensation and Pension evaluation for the knees proximate to separation and records indicated the CI did not report for a scheduled exam.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (analogized to arthritis, degenerative), citing use of AR 635-40, para B-15, (Table of Analogous Codes), normal imaging, no compensable ROM, good stability but “condition prevents performance of duty.”  The VA rated the right knee as the only condition and rated it not service connected (NSC), coded 5010-5260 (arthritis due to trauma – leg, limitation of flexion), based on the STR citing insufficient records received to evaluate the CI’s condition.  In this case, the profile, commander’s comments and the NARSUM all focused on the duty limitation of the right knee.  The MEB did not specify either knee or bilateral knees, while the PEB specified bilateral knees.  Although the left knee condition was not noted as a limiting concern in clinical notes, the Board found that a separate fit/unfit determination was not applicable as neither knee individually, nor both knees together, would rate higher than the 0% assigned by the PEB.  

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for either knee.  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 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 diagnostic imaging evidence of degenerative changes or arthritis of the knees to support a 10% rating under 5003 for “With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups.”  There was no pathway to rating either knee higher than the 0% awarded by the PEB for the bundled knee condition.  Members agreed, therefore, that the evidence did not support recommending separate right and left knee disability ratings.  After due deliberation, and considering all of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled bilateral condition.  

Contended PEB Conditions:  High Frequency Hearing Loss.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

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.  In the matter of the contended high frequency hearing loss condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20150610, 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

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001114 (PD201501075)

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