RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01658
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Military Police, medically separated for “bilateral knee pain due to retropatellar pain syndrome,” with a disability rating of 0%.  

CI CONTENTION:  The CI contended for both knees, his lower back, right wrist and left elbow.  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 - 20050302	VARD - 20050920	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain…	5099-5003	0%	Left Knee Strain	5257	10%	20050823	
			Medial Meniscus tear, Right Knee	5257	10%	20050823	
Lateral Epicondylitis	Not Unfitting	Epicondylitis, left Elbow	5213	0%	20050823	
Pes Planus	Not Unfitting	Bilateral Pes Planus	5275	NSC	20050823	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition was of insidious origin and by self-report, began as early as 1997.  There was no surgical indication and despite treatment, the bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “retropatellar pain syndrome bilaterally w/right greater than left” for PEB adjudication.  
At the MEB examination (recorded on DD Forms 2807 and 2808) dated in December 2004 and January 2005, 5 and 4 months prior to separation, the CI reported bilateral knee pain with swelling with exercise, locking and giving way.  He wore a knee brace and could not run or tolerate prolonged standing.  Physical examination showed bilateral tight hamstrings with right knee joint line tenderness, locking and catch with full extension, and a positive McMurray’s (test for meniscal symptoms).  

The 26 January 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of right knee pain and swelling with bilateral knee pain; right worse than left.  He was unable to stand for prolonged periods and unable to pursue fleeing subjects on foot.  Magnetic Resonance Imaging (MRI) of the right knee showed “nondisplaced tear posterior horn medial meniscus suspected.”  X-ray of the right knee showed minimal narrowing of the medial compartment.  Physical examination showed knee evaluation bilaterally and is charted below.  The diagnosis was “retropatellar pain syndrome bilaterally with the right greater than left.”  

At the 23 August 2005 VA Compensation and Pension (C&P) medical evaluation, performed 3 months after separation, the CI reported bilateral knee pain with use of a neoprene sleeve on the right.  He related that left knee pain and swelling was fairly frequent and thought to be related to favoring his injured right knee.  Physical examination showed a normal gait.  The bilateral knee examination is charted below.  The diagnoses were right knee posterior horn medial meniscus tear with decreased and painful motion, and chronic strain left knee with decreased and painful motion.  

The range of motion (ROM) examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Knee ROM
(Degrees)	Ortho ~7 Mos. Pre-Sep	MEB ~4 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	140	140	140	90	
Extension (0 Normal)	0	0	0	0	
Comment	Pain with McMurray and patellar grind; no laxity or instability	Pain with McMurray and patellar grind; no laxity or instability	Pain with McMurray and patellar grind; no laxity or instability	Painful motion with repetition	
§4.71a Rating	0%	0%	0%	0%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative), and rated 10%, citing “without loss of motion.”  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.  

The VA rated the bilateral knee pain condition as two separate disabilities, one for each knee.  The VA used identical 5257 coding (knee, other impairment of:  recurrent subluxation or lateral instability:) and a rating of 10% for each knee, based on the C&P examination citing decreased range of motion to 90 degrees flexion for each knee.   The VA noted that repetitive motion resulted in no additional pain or limited motion stresses.  

In this case, both knees were considered to fail retention standards, both were implicated by the NARSUM and in 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 that impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.  

The panel noted the disparity between the VA and Service examinations and carefully reviewed the evidence proximate to separation to determine the probative value of each examination.  The VA examination was after separation, the single ROM evaluation in the record which documented pain limited motion, and the NARSUM examination was adjudged to have the highest probative value for rating at separation.  

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for either knee.  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no 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).  Although MRI indicated a likely right knee meniscal tear, there was insufficient evidence of meniscal dislocation, with frequent episodes of “locking,” pain, and effusion into the joint to support rating under code 5258 (cartilage, semilunar, dislocated).  Only one knee (the left) showed evidence of degeneration, and therefore the 5003 10% rating with X-ray evidence of involvement of 2 or more major joints was not supported.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  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 bilateral knee condition.  

Contended PEB Conditions:  Lateral Epicondylitis (Left Elbow), PES Planus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or judged to fail retention standards.  The commander’s statement implicated “pain in the legs” which may have included the Pes Planus condition.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended lateral epicondylitis (left elbow) and PES Planus conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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 20150626, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008582, 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