RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01359
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Health Care Specialist, medically separated for “chronic bilateral knee pain” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that he was given a 0% disability rating by the VA for his chronic knee pain, but it continues to get worse.  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 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 progression or complications of service-connected conditions after separation.  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 - 20050204	VARD - 20051213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Chondromalacia Patella, Left Knee	5099-5024	0%	20050712	
			Chondromalacia Patella, Right Knee	5099-5024	0%	20050712	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:    

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 and rated 10% with application of the US Army Physical Disability Agency pain policy.  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 panel 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.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first presented with bilateral knee pain in November 2003 when he complained of pain while running.  There was no history of acute injury and no surgical indication.  Magnetic resonance imaging (MRI) of the right knee in May 2004 showed degeneration of the posterior horn of the medial meniscus, but a repeat study in July 2005 was normal.  A left knee MRI done in July 2005 showed probable mild patellar chondromalacia (inflammation and softening of cartilage).  Radiographic (X-rays) studies of both knees in June 2005 were normal.  

At a physical therapy evaluation on 4 October 2004, approximately 5 months prior to separation, the CI complained of right knee pain worse than the left.  Current pain severity was 2/10, but increased to 8-9/10 with running, cycling or prolonged standing.  Physical examination noted 145 degrees of knee flexion bilaterally (normal 140) and 10 degrees of hyperextension (normal 0).  The CI was able to squat to 60 degrees with increased pain in both knees.

A clinical summary on 9 November 2004, approximately 4 months prior to separation, noted pain exacerbated by climbing stairs or inclines, and after prolonged sitting or standing.  Swelling and locking were denied.  Physical examination showed a normal gait and normal knee alignment.  Squatting half way caused anterior knee pain.  Knee range of motion (ROM) was “full” but was associated with painful motion.  Knee tenderness was present but crepitus was absent.  The examiner’s assessment was “chronic anterior knee pain bilateral, right side worse than the left.”

The 10 January 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of progressive bilateral anterior knee pain present 100% of the time which caused sleep disturbances.  The CI reported an inability to complete physical fitness testing.  The physical examination showed bilateral patellar tenderness without swelling.  Knee ROM was described as “full.”  The final 11 January 2005 permanent profile listed bilateral chronic anterior knee pain.  The commander’s statement on 26 January 2005 noted the CI was significantly limited by his “conditions” but provided no further elaboration.

At the 12 July 2005 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported that his knee condition began in Basic Training.  He endorsed chronic daily bilateral knee pain with morning stiffness and feeling of giving way and locking.  He was fully employed in security at a casino.  Physical examination showed a normal gait without use of assistive devices or braces.  Knee flexion was normal at 140 degrees bilaterally and extension was normal at 0 degrees.  Painful motion was present at extremes of motion.  There was no additional limitation after repetitive motion.  Knee tenderness was present bilaterally.  Passive motion was associated with a “pop” in the medial aspect of both knees, which was associated with pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy (AR 635-40).  The VA rated the left knee and right knee conditions separately at 0% each, coded analogously to 5024 (tenosynovitis), citing painful motion was absent.  
The panel first considered if the left and right knee pain, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above.  Both knees were profiled, and the commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  

Member consensus was that each knee should be conceded as separately unfitting, and that coding and rating features were logically identical.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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, nonunion, 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 supporting a 10% rating (based on §4.59, §4.40 and §4.45).  In the matter of the bilateral knee condition, the panel majority recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain, the panel majority recommends that each joint be separately adjudicated as follows:  an unfitting chronic left knee pain condition, coded 5099-5003 and rated 10%, and an unfitting chronic right knee pain, condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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	
Chronic Right Knee Pain	5099-5003	10%	
Chronic Left Knee Pain	5099-5003	10%	
COMBINED (w/BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008440, 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