RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01362
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070622

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E7, Construction Engineering Supervisor, medically separated for “chronic right (dominant) wrist pain” and “chronic pain involving both knee joints” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  His wrist condition continues to worsen and impact his daily activities.  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 - 20070604	VARD - 20071022	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right (Dominant) Wrist Pain	5010	10%	Residuals Of Disruption of Scapholunate Ligament, Lunate Triquetral Ligament and Tear of Radial Triangular Fibro Cartilage Off The Radius, Right Wrist	5212	10%	20070712	
Chronic Pain Involving Both Knee Joints	5099-5003	10%	Patellofemoral Pain Syndrome, Right Knee	5260	10%		
			Patellofemoral Pain Syndrome, Left Knee	5261	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Chronic Right (Dominant) Wrist Pain.  The PEB combined the left and right knee pain conditions as a single unfitting condition coded 5099-5003 (analogously to 5003) and rated 10% with application of 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 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 right and left knee pain 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 Board (MEB) narrative summary (NARSUM), the CI injured his right wrist in a motor vehicle accident in 1996 and then again in April 2003 while hitting a punching bag.  This was treated surgically in August 2004.  He was offered fusion, but declined.  In 2005, his wrist began to hurt again and this progressed over the next year.  An MRI on 10 August 2006 noted disruption of some of the ligaments of the wrist and a small loose body.  On 4 October 2006, the CI underwent excision of one wrist bone (scaphoid) and fusion of the 4 surrounding (the scaphoid) bones.  After a period of casting, he was referred to physical therapy for rehabilitation.  

The MEB NARSUM was dated 20 December 2006, 6 months prior to separation, and prepared by one of the treating orthopedic surgeons.  The CI was noted to be in ongoing rehabilitation, but to have continued limitation in motion as charted below.  In orthopedics on 17 January 2007, minimal tenderness was present and the scars were well healed.  The range of motion (ROM) was reduced and is charted below.  A follow appointment in orthopedics on 22 May 2007 noted that the wrist fusion appeared to be successful on X-ray evaluation.  The wrist was stable.  Motion was painful.  The wrist was tender.  

At the VA Compensation and Pension (C&P) evaluation performed on 12 July 2007, 3 weeks after separation, the right dominant CI reported ongoing pain treated with medications and a brace.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Wrist ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	Orthopedics 5 months Pre-Sep 	OT 3 Mo Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Dorsiflexion (70 Normal)	25	10	0/5/3	5	
Palmar Flexion (80)	20	10	10/10/10	10	
Ulnar Deviation (45)	10	5	5/5/5	Pain prevented ROM	
Radial Deviation (20)	2	5	10/5/5	Pain prevented ROM	
Comment	Tenderness present/ limited ROM	Pain at limits of motion		ROM limited by pain	
§4.71a Rating	0%	10%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist pain condition 10%, coded 5010 (traumatic arthritis), noting mechanical limitation in motion.  The VA also rated the right wrist condition 10% coded 5215 (limitation of motion of the wrist), based on the C&P examination 3 weeks after separation.  The limitation in motion supported a 10% rating under the code 5215 and painful, limited motion supported a 10% rating under the code 5010.  No route to a higher rating was found.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right wrist condition.  

Chronic Pain Involving Both Knee Joints.  According to STR and the MEB NARSUM, the CI was first evaluated for left knee pain on 24 January 2005 when he reported that he struck it after jumping out of the cab (of machinery) and hitting his knee on a step.  He was referred to physical therapy where he reported a history of bilateral knee pain.  He underwent rehabilitation and on 4 April 2005, was noted in internal medicine to be able to walk briskly and climb on and off an examination table without limitations or limp.  The examination was normal.  An MRI of the left knee on 11 April 2005 was showed inflammation of a bursa (fluid filled sac) near the knee cap, but was otherwise noted to be normal.  A review by orthopedics noted chondromalacia patella (degeneration of the cartilage lining the kneecap).  X-rays of both knees on 2 August 2006 were unremarkable.  The CI was seen the same day in orthopedics and noted to have a normal examination other than a positive patellofemoral apprehension test.  The ROM was full and pain free motion, the gait was normal.  The CI was diagnosed with bilateral patello-femoral syndrome.  

The NARSUM noted that the CI had pain with squatting as well as climbing stairs.  The ROM is charted below.  The knees were stable and signs of meniscal irritation were absent.  Painful motion was not documented, but crepitus was present with motion, left greater than right.  The X-rays were normal other than signs of patellar beaking (spurring, a sign of degeneration or stress).  In physical therapy on 13 February 2007, the motion was limited in flexion and painful for flexion and extension bilaterally.  The C&P recorded that the CI developed bilateral knee pain after he fell onto both knees from a piece of equipment.  On examination, the gait was normal.  The ROM was full, but painful.  Crepitus was present, but the knees were stable.  X-rays were normal.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Knee ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	PT ~4 Mos. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Flexion (140 Normal)	125	111/112/112	120	
Extension (0 Normal)	0	0/0/0	10	
Comment	Crepitus with ROM; Stable	No swelling or edema/ ROM limited by pain	Pain on motion/ crepitus	
§4.71a Rating	0%	10%	10%	

Right Knee ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	PT ~4 Mos. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Flexion (140 Normal)	125	121/122/123	140	
Extension (0 Normal)	0	0/0/0	0	
Comment	Crepitus with ROM; Stable	No swelling or edema/ ROM limited by pain	Pain on motion/ crepitus	
§4.71a Rating	0%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5099-5003, citing the USAPDA pain policy.  The VA rated the each knee at 10%, coded 5260 (limitation of flexion) for the right knee and 5261 (limitation of extension) for the left knee.  The panel first considered if each knee was separately unfitting.  The CI had a normal gait, when recorded, on multiple examinations.  Flexion was limited, but minimally.  Extension was normal on most examinations other than the C&P examination.  Several X-rays studies were normal, but an MRI was read by the orthopedist as consistent with chondromalacia for the left knee and the NARSUM examiner noted degenerative changes of the patellae.  The MEB determined that the bilateral knee condition was medically unacceptable.  The final profile for the knees listed bilateral as the L3 condition.  While the left knee was clearly more symptomatic, the right was also noted to be problematic.  Accordingly, the panel recommended that each knee be found separately unfitting.  It then considered the ratings.  The limitation in extension for the left knee supported a 10% rating on the VA examination which was most proximate to separation using the code 5261.  The limitation in flexion was not compensable on any examination and the knees were consistently stable when this was documented.  However, painful motion was present and, in the NARSUM, the orthopedic surgeon noted degenerative changes of the patellae (beaking).  This supported a 10% rating using the code 5003.  The panel recommended that each knee be found separately unfitting and rated 10%, each, coded 5261 for the left knee and 5003 for the right.  

BOARD FINDINGS:  In the matter of the right wrist pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral knee pain condition, the panel unanimously recommends a disability rating of 10% each, coded 5261 (left) and 5003 (right) 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Wrist Pain	5010	10%	
Left Knee Pain	5261	10%	
Right Knee Pain	5003	10%	
COMBINED	30% (w/ bilateral factor)	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007560, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency.

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

Sincerely,					       
Enclosure