RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01326
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050323

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Multiple Launch Rocket System Repairer, medically separated for “chronic bilateral knee pain,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention. 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 - 20050125	VARD - 20050422	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Left Knee Strain	5260	10%	20050222	
			Right Knee Strain	5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the left and right knee pain conditions as a single unfitting condition coded 5099-5003 and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  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.  The evidence for the left knee pain and right knee pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in April 2002 while running during basic training, however, he did not seek medical care until July 2002 when his knee pain worsened during Advanced Individual Training.  Diagnostic imaging studies (X-ray and MRI) in March 2004 documented normal knees.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic bilateral knee pain” for PEB adjudication.  

At the 21 December 2004 MEB examination, 3 months pre-separation, the CI reported bilateral knee pain that prevented him from performing his military duties such as lifting heavy objects, negotiating stairs and maneuvering on the missile launcher to perform repairs.  The pain did not prevent him from performing daily living activities, but prevented him from playing basketball.  Physical examination showed normal gait, strength, sensation, and no effusion or edema.  There was bilateral tenderness at the medial knees and both patellae with bilateral patellar grinding.  Examination tests for ligamentous instability and meniscus pathology were negative.  There was full ROM of both knees with associated pain.  

At the 22 February 2005 VA Compensation and Pension (C&P) evaluation, 1 month pre-separation, the CI reported constant knee pain with a grinding sensation, weakness, and stiffness.  The pain was aggravated by standing, walking, and bending and prevented him from walking long distances.  He denied periods of incapacitation and loss of work.  Physical examination showed normal gait and crepitus with no evidence of ligamentous instability or meniscus injury.  The left knee ROM was 0-110 (normal 0-140) and the right knee ROM was 0-100; both limited by pain during flexion.  Diagnostic imaging studies (X-ray) 22 February 2005 showed normal knees with no abnormalities.  

The Board directed attention to the rating recommendation based on the above evidence.  As noted above, the PEB bundled the left and right knee conditions and applied a single 10% rating (coded 5099-5003).  The VA separately rated the left knee condition at 10%, and the right knee condition also at 10%, both coded 5260 (leg, limitation of flexion of), citing painful motion.  

The Board first considered if the bilateral knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  Board members agreed that the evidence reasonably justified that the functional limitations of each separate knee condition contributed to the CI’s inability to perform his military duties, and accordingly separate disability ratings are recommended.  

The Board next considered the evidence for rating.  There was no limitation of flexion or extension of either knee that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 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 these respective codes.  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).  However, there was evidence of painful motion with functional loss of each knee supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, and considering all of the evidence, the Board recommends a separately unfit determination for each knee with disability ratings of 10% for the left and 10% for the right knee conditions.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee patellofemoral syndrome condition rated 10%, and an unfitting left knee patellofemoral syndrome condition, rated 10%, both analogously coded 5299-5261 and IAW VASRD §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	
Left Knee Patellofemoral Syndrome 	5299-5261	10%	
Right Knee Patellofemoral Syndrome 	5299-5261	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150616, 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, AR20170002471 (PD201501326)

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 20% 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