RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01534
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060512

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Multiple Launch Rocket Systems Crewmember, medically separated for “degenerative arthritis, bilateral knees” with a disability rating of 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 - 20060104	VARD - 20070427	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis, Bilateral Knees	5003	10%	DJD, Bilateral Knees	5260-5003	NSC	20070417	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Degenerative Arthritis, Bilateral Knees.  The PEB combined the right and left knee conditions under a single service disability rating, coded 5003 (degenerative arthritis) and rated 10%.  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.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary, the right knee was injured in a football game 10 years prior to entry into service, and underwent surgery to repair damaged cartilage in 1972.  The left knee was injured during basic training in 1980, and the CI experienced periodic bilateral knee pain throughout his time in service.  Magnetic resonance imaging (MRI) performed in December 2004 demonstrated “very prominent…degenerative…arthritic changes...” in the right knee, with bony changes prominent in one part of the knee (lateral, or outward, compartment) and cartilaginous changes prominent in the other area of the knee (the medial, or inward, compartment).  The changes in cartilage were significant enough that the examiner indicated “the medial meniscus is all but absent.”  Further radiographic studies in October 2005 revealed “mild-to-moderate secondary osteoarthritic degenerative changes of both knees, right greater.”  

According to the 24 May 2005 commander’s statement, the CI could not perform his duties, but the statement did not address either knee specifically.  Duty limitations were recommended by the 10 November 2005 Army profile, but the profile addressed both knees bilaterally.  

At the 17 November 2005 physical therapy (PT) appointment, 6 months prior to separation, the CI reported bilateral knee pain rated 0/5 in severity, with exacerbations to 5/10 at worst.  These exacerbations were caused by stair climbing, carrying heavy loads, or walking more than 1/4 mile.  On examination, gait was reported as normal, and range of motion (ROM) was measured across 3 repetitions as 0-128 degrees (normal 0-140) on the right and 0-130 degrees on the left, with no increase in pain on motion.  

During the 28 November 2005 MEB NARSUM examination, 5 months prior to separation, the CI reported occasional bilateral knee pain and popping, with the pain rated 5/10.  Physical examination showed normal gait and stance, and the CI could heel and toe walk without difficulty.  There was no swelling, warmth, or redness of the knee joints.  Testing for ligamentous laxity was negative.  Crepitus (a grinding or popping sound or sensation) was also reported, with the right knee greater than the left.  ROMs were as reported in the PT examination (above).  That same day, at the MEB examination (recorded on DD Forms 2807-1 and 2808), ROM for the bilateral knees “appeared grossly normal.”  

At the 17 April 2007 VA Compensation and Pension (C&P) evaluation, performed 11 months after separation, the CI reported bilateral knee pain increased with walking, and stiffening of the knees if he stood or sat too long.  Physical examination showed negative tests for ligamentous laxity and cartilage damage.  ROM was recorded as 0-135 degrees with painful motion, with no changes on repetition.  Radiographic study revealed post-traumatic arthritis of the right knee.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5003 (degenerative arthritis), citing X-ray evidence without ratable limitation of motion.  The VA determined the bilateral knee condition was not service connected , citing a lack of evidence that the knee conditions were incurred or aggravated beyond normal progression by service.  

Directing attention to its fitness and rating recommendations, the panel first considered that in this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and the commander’s statement; and, both were profiled.  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.  Since undue speculation would be required to conclude impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.  

As noted above, there are no distinctions with regards to fitness considerations between the right and left knees.  Functional limitations were not able to be ascertained to differentiate between the knees, though the right knee clearly had significantly worse pathology than the left.  The panel adjudged that the NARSUM/PT examination which was closest to separation had the highest probative value for rating at separation.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no objective evidence of painful motion for either knee.  The right knee had meniscal surgery, however there was no history of frequent locking with recurrent effusions (5258) to support a rating under those respective codes.  The 5259 code (cartilage, semilunar, removal of, symptomatic) for the right knee would not provide any higher rating than that adjudicated by the PEB, as the left unbundled knee would rate 0%.  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).  The bilateral degenerative arthritis diagnosis with X-ray evidence supported a single 5003-based rating for “2 or more major joints” without compensable limitations or painful motion.  There were no incapacitating exacerbations and the 5003 rating would be no higher than 10%.  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, and considering all of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled knee conditions.  

BOARD FINDINGS:  In the matter of the bilateral knee condition 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 that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150621, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008578, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure