RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01321
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050117

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

CI CONTENTION:  The CI contended for both knees.  The CI’s 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 - 20041123	VARD - 20050808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Bilateral Patellofemoral Arthrosis	5003	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

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 in 2001 during Basic Training after running and falling onto both knees.  Orthopedic evaluation dated 27 April 2004 noted complaints of continued bilateral knee pain.  Examination documented bilateral knees with full range of motion (ROM) without pain, and no tenderness, swelling or laxity.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral patellofemoral arthrosis with knee pain” for PEB adjudication.  

The MEB NARSUM examination on 14 July 2004, 6 months prior to separation, noted complaints of bilateral knee pain.  Physical examination showed bilateral pain with patellofemoral compression, lateral tracking of the patellas, and tenderness.  There was no instability of either knee.  The ROM of the right knee was 0-110 degrees (normal 0-140) and the left knee ROM was 0-115 degrees.  X-rays showed bilateral patellar tilt and small patellar osteophytes bilaterally.  There was no VA Compensation and Pension examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The Formal PEB combined the left knee and right knee pain conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 0%, citing 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 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 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 VA rated the bilateral knee pain condition 0% coded 5003 (arthritis, degenerative), citing a noncompensable evaluation indicating that the CI failed to report for examination and therefore the level of current disability was unknown.  

The record from 2002 forward addressed bilateral knee pain as a single condition with most exams indicating bilateral knee findings.  Separate left and right knee evaluations, where present, were clinically and functionally similar.  Panel members agreed that the evidence reasonably justified that the functional limitations of each knee condition contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings were considered.  The panel then considered its rating recommendation for the unfitting right knee condition and for the unfitting left knee condition at the time of separation.  

As noted above, there were no distinctions with regards to clinical features or fitness considerations between the right and left knees.  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 for either knee.  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).  No additional functional limitation was evidenced by the examinations.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than 0% for either knee separately.  However, the bilateral diagnosis supported a single 5003 based 10% rating for “2 or more major joints” with evidence of degenerative changes (osteophytes) without significant ROM limitations or painful motion; thus there is VASRD §4.71a latitude for a bilateral rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the bilateral knee pain condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’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	
Bilateral Knee Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009047, 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