RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01122
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070131

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Financial Management Technician, medically separated  for “chronic bilateral knee pain” with a disability rating of 0%.

CI CONTENTION:  The CI requested a review 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 - 20070110	VARD - 20070730	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	0%	Patellofemoral Syndrome, (Knee) Right, with Minimal
Enthesopathy	5299-5257	0%	20070418	
			Patellofemoral Syndrome, (Knee) Left, with Minimal
Enthesopathy	5299-5257	0%	20070418	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB adjudicated the bilateral knee pain condition as a single unfitting condition analogously coded 5003 (degenerative arthritis) rated 0%, with application of the US Army Physical Disability Agency (USAPDA) policy/guidance Memorandum #12: Table of Analogous Codes.  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 or implied adjudication that each condition was separately unfitting.  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.  The evidence for the bilateral knee pain condition is presented for both knees together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic bilateral knee pain condition began in 1998 without specific trauma.  There was no surgical indication.  He was issued a profile and referred to physical therapy.  Imaging studies, including MRIs, X-rays, and a bone scan were unremarkable other than a small effusion (fluid) noted on the left knee MRI.  The diagnosis of patello-femoral syndrome was made.  He was able to perform his adequately until April 2006 when he could no longer make the time criterion for the walk portion of physical fitness testing.  He was consistently noted to have normal or near normal and pain free range of motion (ROM).  The knees were stable and signs of meniscal (internal cartilage cushions) were absent.  The MEB forwarded “patellofemoral syndrome” for PEB adjudication.  The MEB NARSUM examination on 21 December 2006, 1 month prior to separation, noted complaints of constant pain with daily activities.  The physical examination recorded painful, but near normal ROM measurements.  At the VA Compensation and Pension (C&P) evaluation performed on 18 April 2007, 3 months after separation, the CI reported constant pain rated in both knees, associated with stiffness, swelling, redness, and occasional instability and popping sensations.  The pain was exacerbated by walking longer than an hour climbing stairs.  It was alleviated with rest and heat.  The CI used a knee brace as needed, but the use of one was not documented on the examination.  The ROM exceeded VA normal values and painful motion was not documented.  There was no further limitation with 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 5099-5003 (arthritis, degenerative), citing range of motion limited by pain.  The VA rated the bilateral knee pain condition using separate ratings for each knee.  The ratings were identical at 0% for each knee, analogously coded 5299-5257 (knee, other impairment of: recurrent subluxation or lateral instability), based on the VA C&P examination 3 months after separation, citing a non-compensable evaluation.  The Board first considered if the left or right knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left knee was specifically profiled and was cited by the commander as a duty limiting condition.  The right knee was not evaluated separately from the left other than for imaging studies.  The final clinical notes only addressed the left knee.  The only pathology on imaging was the effusion noted for the left knee.  Although the right knee was noted as symptomatic, a preponderance of treatment notes showed the CI’s right knee was not as disabling as his left knee condition.  A finding that the right knee was separately unfitting is not supported.  Radiographic evidence of the presence of degenerative arthritis was not present and a 10% rating for the bilateral knee condition in the IAW VASRD code 5003 for painful motion is not supported.  There was no evidence for instability or meniscal pathology to support a rating.  The CI was clearly limited, though, as documented by the commander and numerous clinical notes and a 10% rating IAW VASRD §4.40 (functional loss) is supported using the analogous code 5299-5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral knee pain condition, coded 5299-5003.  
BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the Board unanimously recommends a disability rating of 10% for the bilateral knee condition, coded 5299-5003 IAW VASRD §4.40 and 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	
Chronic Bilateral Knee Pain 	5299-5003	10%	

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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170002609 (PD201501122)

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 10% 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