RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2015-01429
BRANCH OF SERVICE:  army	SEPARATION DATE:  20060809

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Indirect Fire Infantryman, medically separated for “chronic bilateral knee pain,” rated 10%.  

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 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 - 20060615	VARD - 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	10%	Left Knee Strain	5260	10%	20070201	
			Internal Derangement…Right Knee	5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  The PEB combined the left knee and right knee conditions as a single unfitting condition coded 5099-5003 (analogous to degenerative arthritis) 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 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 whether 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 Disability Evaluation System or 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 Board (MEB) narrative summary (NARSUM), the CI underwent right knee surgery in January 2006.  During the MEB examination dated 19 May 2006, 3 months prior to separation, the CI reported right knee pain with swelling and locking, and periodical giving out with standing for long periods.  The pain prevented him from performing his military duties.  Physical examination showed normal gait and strength.  There was no effusion (fluid buildup in the knee joint) and no ligamentous instability or cartilage pathology.  Testing for kneecap pathology (patellar grind test) was positive, and tenderness of the knee was noted. Range of motion (ROM) was recorded at 0-140 degrees (normal 0-140).
  
At the 1 February 2007 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported chronic knee pain with swelling, bruising, and shooting pain along his knee rated 8/10 in severity, with flares of pain at 10/10 radiating up his thighs due to cold weather or increased humidity.  The pain was relieved by medication (Tylenol, Motrin) and analgesic ointment.  The CI stated he used a sports brace and a hinged brace at times.  Physical examination showed steady gait.  Examination tests for ligamentous instability and cartilage pathology were negative, and there was no swelling or redness.  Tenderness of the knee was noted, which the examiner attributed to old bruising, and noted to be resolving at the time of the examination.  ROM was recorded as 0-130 degrees, limited by pain.  Radiographic studies showed soft tissue fullness in the suprapatellar region, with small joint effusion not excluded.  The joint spaces were well maintained and bony structures were intact without fracture or destructive bony lesion.

The panel first considered whether the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As discussed, the PEB rated both knees combined according to the USAPDA pain policy.  The VA rated the right knee condition 10%, coded 5260 (leg, limitation of flexion of), citing limitation of motion.

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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) 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Panel members agreed the evidence indicated the right knee condition reasonably contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating could be recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel determined that a separate disability rating of 10% for the right knee condition, coded 5003, was justified.

Chronic Left Knee Pain.  According to STR and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in 1993 during a previous enlistment, and began to hurt again in 2000, with no indication for surgical repair.  During the MEB examination dated 19 May 2006, 3 months prior to separation, the CI reported worsening left knee pain with occasional mild swelling.  He reported the left knee did not lock or give out, but the pain prevented him from performing his military duties.  Physical examination showed normal gait and strength.  There was no effusion and examination tests for ligamentous instability and cartilage pathology were negative.  Testing for kneecap pathology was negative.  ROM was recorded as normal (0-140 degrees).
  
At the 1 February 2007 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported chronic knee pain with swelling, bruising, and shooting pain along his knee rated at 8/10 in severity, which flared to 10/10 and radiated up his thighs due to cold weather or increased humidity.  The pain was relieved by medication (Tylenol, Motrin) and analgesic ointment.  The CI stated he used a hinged brace for his left knee at times.  Physical examination showed steady gait.  Testing for ligamentous instability and cartilage pathology were negative and there was no swelling or redness.  Tenderness of the knee was noted, which the examiner attributed to old bruising, and noted to be resolving at the time of the examination.  ROM was normal was recorded as normal, with no painful motion documented.  Radiographic studies were unremarkable.

The panel first considered whether the left knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As discussed, the PEB rated the chronic bilateral knee pain according to the USAPDA pain policy.  The VA rated the left knee separately at 10%, coded 5260 (limitation of leg flexion), citing limitation of motion.  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).  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 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 insufficient evidence to support a rating higher than 0%.  The panel agreed that while the right knee disability could be rated separately at 10% and the left knee at 0%, this would provide no benefit to the CI.  After due deliberation, and considering all of the evidence, the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic bilateral knee pain.

PANEL FINDINGS:  In the matter of the chronic bilateral knee pain and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no re-characterization of the CI’s disability and separation determination.  

AR20200000967

Dear XXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,