RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01881
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Indirect Fire Infantryman, medically separated for “bilateral knee pain,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  The CI’s 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 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 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 determinations 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 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 -20040923	VARD - 20051205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Joint Disease of Both Knees	5003	10%	Degenerative Joint Disease…Right Knee	5010-5014	10%	20041116	
			Degenerative Joint Disease…Left Knee	5010-5014	10%	20041116	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Degenerative Joint Disease Right Knee Diagnosis.  The PEB assigned a disability rating of 10% for member’s bilateral knee pain disorder, collectively the result of right and left knee pain.  Although VASRD §4.71a permits combined ratings, it allows separate ratings for separately compensable joints.  The PEB must follow suit (IAW DoDI 6040.44) if the PEB’s combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the right and left 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’s right knee condition began in January 1996 when the CI sustained a lateral collateral ligament strain while playing football.  His treatment at that time was conservative.  Several months after the initial injury, the CI re-injured the knee while playing basketball and subsequently reported constant pain and recurring effusions.  Radiographic study completed on 8 July 1996 showed early degenerative changes and a possible loose body.  On 29 October 1996, the CI underwent a right knee ACL reconstruction with a bone-tendon-bone graft and debridement of the meniscus tear.  The CI returned to full duty in 18 months, but continued to have pain off and on resulting in temporary profiles.  Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral knees: degenerative joint disease” for PEB adjudication.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated August 2004, 3 months prior to separation, physical exam of the right knee showed positive patellar compression test (mild), no warmth, no laxity, and no effusion.  The MEB NARSUM examination 26 August 2004 of the right knee, 3 months prior to separation, noted some paresthesia’s at the anterior cruciate ligament (ACL) site consistent with the infrapatellar branch of the saphenous nerve distribution.  The MEB NARSUM examination on 7 September 2004, 2 months prior to separation, noted limited duty with inability to carry a full combat load, foot march or perform the two mile run.  Physical examination of the right knee showed no warmth, but positive patellar compression test.  Right knee flexion was 125 degrees (140 Normal) and an extension of 0 degrees (0 Normal).  At the 16 November 2004, VA Compensation and Pension (C&P) evaluation, performed at separation, the CI reported flares, one to six times a month, lasting one to two days.  Pain was aggravated by standing in one place for less than 5 minutes, cold weather, climbing stairs, or physical activity.  Pain intensity reported at 4/10 bilaterally.  Physical examination showed ligaments stable.  Drawer sign (clinical assessment of suspected rupture of the cruciate ligaments in the knee), Lachman (clinical test used to diagnose injury of the anterior cruciate ligament) and McMurray test (evaluate individuals for tears in the meniscus of the knee) on repetition, were negative but did cause mild to moderate aggregation of pain.  Right knee flexion was 135 degrees (140 Normal) and an extension of 0 degrees (Normal).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5003 (arthritis, degenerative) citing degenerative arthritis with no instability and two or more major joints with x-ray evidence.  The VA rated the right knee condition 10% coded 5010-5014 (arthritis-osteomalacia) and the left knee condition 10% coded 5010-5014 (arthritis-osteomalacia), citing limitation of motion for a major joint.  Directing attention to its recommendations, the panel considered if bilateral knee pain condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Both knees were profiled, but only the left knee was implicated in the commander’s statement, but both were judged to contribute to the unfitting pain disorder.  Members agreed, therefore, that the preponderance of evidence supported that the left and right knee condition were justified as separately unfitting and that they each met VASRD §4.71a criteria for a separate rating.  The panel noted that multiple treatment notes documented left and right knee pain along with radiographic evidence.  The panel noted that multiple treatment notes documented right knee pain along with radiographic evidence.  There was no limitation of motion which supported a 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 dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  There was no non-union, or malunion fracture of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, the panel concluded that there was sufficient evidence of painful motion and functional loss to support a 10% rating for the right knee IAW §4.59, §4.40 and §4.45.  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 pain condition, coded 5003.  

Degenerative Joint Disease Left Knee Diagnosis.  According to STR and the MEB NARSUM, the CI’s left knee condition began in October 2002 while deployed to Kuwait.  The CI reported progressive left knee pain with swelling.  Internal derangement was suspected.  No trauma or injury reported.  Radiographic studies on 21 October 2002, following a significant effusion, showed separation of the tibial tuberosity consistent with old Osgood-Schlatter’s disorder.  On 15 January 2003, Magnetic Resonance Imagining (MRI) showed a large effusion, multiple cartilaginous loose bodies, increased signal in the posterior horn of the medial meniscus without a definite tear, a partial tear of the ACL, moderate degenerative changes of the medial compartment, and a possible flap of the medial margin of the medial patellar cartilage.  On 10 February 2003, orthopedics recommended surgery.  However, the CI deployed to Iraq where he required duty limitations.  In March 2004, the CI returned from his deployment.  MRI studies in March 2004, and x-ray studies in April 2004, of the left knee, showed degenerative joint disease.  On 12 April 2004, the CI underwent a left knee chondroplasty and placed on a permanent '2' profile.  In June 2004, the CI was placed on a permanent '3' profile due to continued knee pain and swelling.  Despite treatment, the left 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 “bilateral knees: degenerative joint disease” for PEB adjudication.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated August 2004, 3 months prior to separation, physical examination showed left knee with very slight warmth, positive patellar compression test (mild), and tenderness to palpation.  The MEB NARSUM examination 26 August 2004, 3 months prior to separation, noted left knee range of motion flexion of 120 degrees (Normal 140) with no effusion.  The MEB NARSUM examination on 7 September 2004, 2 months prior to separation reported above.  At the 16 November 2004, VA Compensation and Pension (C&P) evaluation the CI reported flares, 1 to 6 times a month, lasting 1 to 2 days.  Pain was aggravated by standing in one place for less than 5 minutes, cold weather, climbing stairs, or physical activity.  Pain intensity reported at 4/10 bilaterally.  Physical exam showed ligaments stable.  Drawer sign (clinical assessment of suspected rupture of the cruciate ligaments in the knee), Lachman (clinical test used to diagnose injury of the anterior cruciate ligament) and McMurray test (evaluate individuals for tears in the meniscus of the knee) on repetition, were negative but did cause mild to moderate aggregation of pain.  Left knee flexion was 135 degrees (140 Normal) and an extension of 0 degrees (Normal).

The panel directed attention to its rating recommendation based on the above evidence.  The panel noted that multiple treatment notes documented left knee pain along with radiographic evidence.  There was no limitation of motion which supported a 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 dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  There was no non-union, or malunion fracture of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, the Board concluded that there was sufficient evidence of painful motion and functional loss to support a 10% rating for the right knee IAW §4.59, §4.40 and §4.45.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee pain condition, coded 5003.  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 left knee pain condition, coded 5003 (arthritis, degenerative).  

BOARD FINDINGS:  In the matter of the right knee and left knee condition, the panel unanimously recommends a disability rating of 10% for the right knee and 10% for the left knee each coded 5003 for a combined rating of 20%  IAW VASRD §4.71a.  There were 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 Pain	5003	10%	
Left Knee Pain	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150708, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009234, 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