RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01553
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “bilateral knee pain without any specific history of trauma or injury,” with a disability rating of 10%.  

CI CONTENTION:  The CI requests the Board consider all conditions.  The CI’s 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 upon a 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 - 20030630	VARD - 20031015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5009-5003	10%	Retropatellar Pain Syndrome, Right Knee	5099-5014	10%	20030917	
			Retropatellar Pain Syndrome, Left Knee	5099-5014	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain began shortly after joining the Army in September 2002, with left knee pain during basic training.  By December 2002 the CI also began having right knee pain.  Radiographic studies included a left knee X-ray on 19 December 2002 that revealed “normal left knee,” and a left knee magnetic resonance imaging (MRI) study on 24 December 2002 that reported possible early meniscal degeneration with "essentially normal” knee.  There was no surgical indication, and conservative treatment including periods of rest, non-steroidal anti-inflammatory medications, knee supports and physical therapy did not result in improvement sufficient to allow return to training or unrestricted duty.  The MEB forwarded “persistent bilateral knee pain secondary to retropatellar pain syndrome and iliotibial band syndrome with evidence of mild left knee degenerative changes” for PEB adjudication.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 12 February 2003, 7 months prior to separation, the CI reported pain with walking and “numbness” of the lower extremities.  Physical examination showed “chronic bilateral knee pain; full active range of motion (ROM) with crepitus.”  The MEB NARSUM examination on 15 May 2003, 3 months prior to separation, noted complaints of bilateral knee pain, left greater than right, aggravated by running, jumping, squatting, prolonged sitting and standing.  Physical examination showed a normal gait with “full active range of motion” of the extremities, normal gait, no joint instability, negative varus and valgus stress and negative McMurray's test (for meniscal pathology).  

At the 17 September 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month after separation, the CI reported pain and stiffness of both knees, pain when running, walking, climbing stairs or standing for a lengthy time.  Physical examination showed a normal gait, right knee flexion of 125 (normal 140), left knee flexion of 135 (normal 140); with 7 degrees increased flexion of each knee with passive (ROM) testing.  There were no signs of crepitus or laxity.  The CI had difficulty rising from a squat.  There was no motor, sensory, or reflex deficit in either lower extremity.  

The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 and rated them a combined 10% with application of the USAPDA pain policy AR 635-40 B24.f.  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 bilateral knees were presented together as they were examined and discussed together in the STR.  

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left knee and right knee conditions as bilateral knee pain and applied a single 10% rating coded 5099-5003 (arthritis, degenerative), citing application of the USAPDA pain policy.  The VA rated the left knee condition 10% coded 5099-5014 (osteomalacia), and rated the right knee condition 10% coded 5099-5014; both based on the VA C&P examination 1 month after separation, citing painful motion of a major joint for each knee.  The NARSUM and other STR evidence did not provide sufficient information which would permit the Board to discriminate the performance limitations attributable to either knee joint over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with return to military training, members agreed that each knee was reasonably justified as separately unfitting.  

The Board next addressed ratings for each unfitting knee.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The Board consensus was that there was insufficient objective evidence of painful motion and functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) for either knee.  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 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).  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board consensus was that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee pain condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification to 20% and did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

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

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001293  (PD201501553)

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, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA