RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01950
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050414

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Mental Health Specialist, medically separated for “bilateral knee pain” with a disability rating of 10%. “Bilateral foot pain secondary to bilateral flexible pes planus,” was determined to have existed prior to service (EPTS) and was not rated 

CI CONTENTION:  Current conditions support a higher rating.  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 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 confined to 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 - 20050308	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	No VA Examination in Evidence	
Bilateral Foot Pain Secondary to Bilateral Flexible Pes Planus	5299-5276	EPTS		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

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 condition began in 2004 during basic training.  Initial X-rays of both knees were normal.

During the 25 January 2005 MEB NARSUM examination, 3 months before separation, the CI reported painful underneath both kneecaps.  Physical examination revealed full range of motion of both knees.  Bilateral kneecap grind was present.  There was no evidence of local bruising, effusion, or instability.  Lower extremity strength was good.  Bilateral symptomatic retropatellar pain syndrome was diagnosed.

There was no VA examination performed for this panel’s analysis.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions under a single disability rating, analogously coded 5099-5003 (degenerative arthritis), and rated 10%, citing the US Army Physical Disability Agency pain policy. This 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 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 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.  

Panel members carefully considered the persistent and subjective symptoms of bilateral knee pain and although the left knee singularly appeared more objectively impaired than the right, members concluded that the CI’s overall condition, isolated conservative treatments, and generally unchanging clinical symptoms did not significantly center about either knee independently, but were rather that of a bilateral condition.  Panel members found it reasonable to surmise that it was the combination of pathology from both knees that rendered the CI unfit to perform her military duties.

Panel members next agreed that the absence of STR or VA evidence, to include limited motion, joint locking, bone fracture, surgical history, or painful motion, did not support a rating higher than 10% as adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

Bilateral Foot Pain Secondary to Bilateral Flexible Pes Planus.  The CI’s bilateral foot pain condition also began during basic training.  X-rays revealed bilateral pes planus without evidence of fracture or arthritic change.

The case file contained the CI’s military entrance physical examination, dated 01 December 2003, which clearly identified the CI having “asymptomatic moderate pes planus.”  At the 25 January 2005 MEB NARSUM examination, the CI reported pain on the under surface of both feet to include the heel.  Physical examination revealed mild tenderness along the underside of both feet.  There was no evidence of crepitus or other foot deformity.  The examiner listed the following prognosis: “The [CI] has not responded to profiling and non-operative management of her conditions.  Her symptoms will likely improve and resolve with activity modification and time.  However, it is unlikely that she will be [able to] resume active duty military training and service without reoccurrence and/or progression of her symptoms.”

The PEB determined that this bilateral foot condition was EPTS.  The condition was specifically cited on the DD Form 199 as, “There is compelling evidence to support a finding that the current condition [is] EPTS and was not permanently aggravated beyond natural progression by such service.  Flexible pes planus is a pre-existing condition.  Since Soldier's symptoms started in basic training, there is no evidence of permanent service aggravation [PSA], Soldier's symptoms should resolve upon return to normal footwear and activities.”

The panel members first focused on determining whether there was PSA of the bilateral foot condition.  All panel members agreed that the increase in required physical activities did indeed aggravate the pre-existing pes planus condition; however, the MEB NARSUM examination most proximate to separation documented mild bilateral tenderness under both feet without crepitus, foot deformity, and no fracture or arthritic change per X-ray.  The panel concluded that such service aggravation was not considered “permanent” in nature and agreed with the MEB NARSUM examiner that a return to normal footwear and activities would equate to symptom resolution.  There was no VA examination for this panel to further consider permanent aggravation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the panel recommends no change in the PEB’s adjudication of EPTS without PSA for the bilateral foot condition.

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral foot pain condition, the panel unanimously recommends no change in the PEB’s finding of EPTS without PSA.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20150713, w/atchs
Exhibit B.  Service Treatment Record

AR20170011807, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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,