RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01279
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070827

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

CI CONTENTION:  The CI made no specific contention.  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 Panel (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 Board’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 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 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 - 20070626	VARD - 20080509	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Status Post, Left Knee Arthroscopy for Meniscal Tear 	5299-5259	0%	STR	
			Right Knee Arthralgia	5299-5257	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Left Knee.  The PEB combined the left knee and right knee conditions as a single unfitting condition coded 5099-5003 and rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 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 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 DES 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 evidence for the left knee and right knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Panel (MEB) narrative summary (NARSUM), the CI’s left knee condition began in October 2005 after jumping from a vehicle and twisting his knee.  Arthroscopic surgery was performed July 2006.  Diagnostic imaging studies (X-ray) 3 January 2007 were negative.  Diagnostic imaging studies (MRI) 13 January 2007 indicated postoperative changes lateral meniscus and or small free edge radial tear. There was prior medial collateral ligament injury.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left knee pain after arthroscopic knee surgery for debridement of a tear to the medial meniscus with continued pain, diagnosed as patellofemoral pain syndrome” for PEB adjudication.  

The Orthopedics exam, dated 15 May 2007, noted pain 3/10 but up to 8-9/10.  He denied radiation but complained of popping at quad and patella region.  He had quit playing contact and cutting sports.  Examination of left knee showed crepitus in the patella, tenderness on palpation, full range of motion, positive medial McMurray test and apprehension tests, no effusion, no deformity, and no medial or lateral instability or anterior instability.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 21 May 2007, 3 months prior to separation, the CI reported significant left knee pain with occasional locking of the knee.  The pain was present 80% daily and was relieved by medication (Advil).  The physical examination showed tenderness to the medial greater than the lateral joint lines.  There was positive grind with crepitus noted.  There was no patellar tilt or laxity but there was tenderness to palpation over the mid substance of the patellar tendon.  There was no erythema of the patellar tendon however.  Examination tests for ligamentous instability and meniscus pathology were negative with pain.  The ROM was mildly limited in flexion / extension.  Diagnostic imaging (X-ray) studies 17 October 2007 revealed no acute fracture, joint space narrowing, or joint effusion.  There was normal patella alignment.  

The Panel first considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As noted above, the PEB bundled the left knee condition with the right knee condition and applied a single 0% rating analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Pain Policy rating of minimal and constant.  The VA rated the left knee condition 0%, coded 5299-5259 (cartilage, semilunar, removal of, symptomatic), citing no evidence of the degree to which the knee condition was disabling and the removal of the semilunar cartilage was not symptomatic.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation, the Orthopedics examination 15 May 2007 and the NARSUM examination 21 May 2007 (1 week later), demonstrated a negative instability test with pain.  There was no fracture, non-union, or mal union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, as mentioned, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, and considering all of the evidence, the Panel recommends a separately unfit determination with a disability rating of 10% for the left knee condition.  

Right Knee.  According to service treatment records (STR) and the Medical Evaluation Panel (MEB) narrative summary (NARSUM), the CI’s right knee condition began in February 2006 (four months after injuring his left knee) when he began experiencing occasional pain.  Diagnostic imaging studies (X-ray) 3 January 2007 were negative.  Diagnostic imaging studies (X-ray) 21 May 2007 showed normal alignment with no fracture, osteochondral defect, bone lesion, or abnormal sclerosis.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right knee pain diagnosed as arthralgia” for PEB adjudication.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 21 May 2007, 3 months prior to separation, the CI reported right knee pain with a grinding sensation accompanied by slight to mild pain.  He denied locking or instability of the right knee.  The pain was present less than 25% daily.  The physical examination showed no edema or effusion and no tenderness to palpation over the patellar tendon.  Examination tests for ligamentous instability and meniscus pathology were negative.  The ROM was mildly limited in flexion 135 degrees (normal is 140 degrees) and in extension 5 degrees (normal is 0 degrees).  Diagnostic imaging (X-ray) studies 17 October 2007 revealed no acute fracture, joint space narrowing, or joint effusion. There was normal patella alignment.  

The Panel first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As noted above, the PEB bundled the right knee condition with the left knee condition and applied a single 0% rating analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Pain Policy rating of minimal and constant.  The VA rated the right knee condition not service connected, analogously coded 5299-5257 (knee, other impairment of:  recurrent subluxation or lateral instability), citing no abnormality from STR X-ray evidence.  

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 fracture, non-union, or mal union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  Therefore the Panel concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  The Panel members concluded that the preponderance of evidence showed the right knee condition would not reasonably have caused the CI to be referred into the DES or be found unfit due to the right knee condition.  

PANEL FINDINGS:  In the matter of the chronic bilateral knee pain condition, the Panel unanimously recommends that it be adjudicated for two separate conditions:  In the matter of the left knee condition, the Panel unanimously recommends a separately unfit determination with a disability rating of 10%, coded 5003.  In the matter of the right knee condition, the Panel unanimously agrees that it cannot recommend a finding of unfit for additional service disability rating.  There were no other conditions within the Board’s scope of review for consideration.  The Panel 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 Left Knee Pain	5099-5003	10%	
Chronic Right Knee Pain	5099-5003	--	
COMBINED	10%	

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

	

AR20170005979, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure