RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-01820
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  2060228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Automated Logistical Specialist, medically separated for “chronic knee pain,” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20051221	VARD - 20061017	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Knee Pain	5099-5003	10%	Left Knee Condition	5299-5260	NSC	20060712	
			Right Knee Condition	5299-5260	NSC	20060712	
Low Back Pain	Not Unfitting	Lumbar Spine with Sciatica	5299-5237	NSC	20060712	
Pseudofolliculitis Barbae		Pseudofolliculitis Barbae	7820	0%	20060712	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 and rated 10% with application of the 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 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 evidence for the right and left knee pain conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in 1995 when he twisted his left knee playing football.  In 1997 he complained of bilateral knee pain around the knee cap while running.  Knee X-rays showed bilateral-lateral patella tilt and the CI was diagnosed with patellar chondromalacia.  MRI’s were normal bilaterally.  An MRI of both knees performed on 31 August 2005 showed intact ACL and PCL, no meniscal abnormalities, and no evidence of chondromalacia patella.  The 15 September 2005 commander’s statement implicated chronic knee pain as impairing the CI’s duty performance, without specifying right, left or bilateral.  The 9 December 2005 permanent profile listed bilateral knee pain.  Bilateral knee range of motion (ROM) measured on 18 November 2005 was right knee extension 0 degrees (normal 0) and flexion 110 degrees (normal 140) and left knee extension 5 degrees and flexion 105 degrees, with painful motion of both knees.  Pain was elicited by flexion and extension of both knees.  

The 8 December 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of a pulling pain on the kneecaps and on the medial side of his knees, left greater than right, increasing when he ran for 10-15 minutes or walked for 25-30 minutes.  Physical examination showed a gait with intact motor strength, reflexes and sensory.  The examiner referred to the above ROM measurement.  The MEB NARSUM examiner determined that the CI fell below retention standards due to his bilateral knee conditions.  

At the 12 July 2006 VA Compensation and Pension (C&P) evaluation, 5 months after separation, physical examination showed normal ROM in both knees with extension-flexion of 0-140 degrees with no additional limitation by pain, fatigue, weakness, or lack of endurance after repetitive use.  Knee X-rays were normal with no evidence of subluxation, dislocation, or fracture.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if both the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  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.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the both the right knee and left knee conditions were reasonably considered separately unfitting.  Since the relevant clinical evidence was similar for both knees the panel then considered its rating recommendation for the unfitting knee conditions together at the time of separation.

The PEB rated the bilateral knee pain condition 10%, coded 5099-5003 (arthritis, degenerative), citing pain rated as slight and constant under the US Army Physical Disability Agency (USAPDA) pain policy.  The VA did not service connect the bilateral knee condition, citing that the CI had “normal bilateral knees with no significant effects on usual occupation or problems following daily activities.”   

There was sufficient evidence of painful motion and functional loss to support a 10% rating for each knee IAW §4.59 and §4.40 noted by the MEB NARSUM examination.  In considering routes to a higher rating however, there was no limitation of motion of either knee which attained a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (5261).  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 either knee under the respective codes.  There was no fracture, non-union, or malunion of either 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 10% for either knee under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee pain condition, coded 5099-5003.  

Contended PEB Conditions:  Low Back Pain; Pseudofolliculitis Barbae.  The panel’s main charge is to assess the fairness of the PEB’s determination that low back pain and pseudofolliculitis barbae were not unfitting.  Although both conditions were profiled, there was no performance-based evidence from the record that either condition 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 either of the contended conditions and so no additional disability rating are recommended.   

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends a disability rating of 10% for each knee, coded 5099-5003  IAW VASRD §4.71a..  In the matter of the contended low back and pseudofolliculitis barbae conditions, the panel unanimously recommends no change from the PEB determination.  There are 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Knee	5099-5003	10%	
Left Knee 	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20170008808, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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

Sincerely,	
Enclosure