RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01973
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Automated Logistical Specialist, medically separated for “chronic bilateral knee pain” and “left ankle pain, paresthesia of foot status post tarsal tunnel releases,” each rated at 10%, with a combined disability rating of 20%.   

CI CONTENTION:  “Review all conditions.”  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 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 panel 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 - 20030811	VARD - 20040127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Bilateral Degenerative Joint Disease with Patellofemoral Pain Syndrome of Knees	5010	10%	20031010	
Left Ankle Pain, Paresthesia of Foot Status Post Tarsal Tunnel Releases	8799-8725	10%	History of Left Ankle Strains with Postoperative Tarsal Tunnel Release of Left Foot	5299-8622	0%	20031010	
Left Shoulder Pain After Surgery	Not Unfitting	Status Post Surgical Repair due to Degenerative Joint
Disease of Acromiocla Vicular Joint with Tear of the
Rotator Cuff of Left Shoulder (Non Dominant)	5203	0%	20031010	
Pes Planus	Not Unfitting	Bilateral Pes Planus	5276	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported he had many years of bilateral knee pain and used knee braces in the past.  The CI experienced pain and swelling of his knees, with the left being worse than the right, especially with running.  Radiographs of bilateral knees in October 2002 were normal and MRI of left knee was normal.  

At the 10 April 2003 MEB NARSUM examination, the CI complained of bilateral knee pain, which were painful “all day, every day.”  Wearing knee braces helped somewhat, and he took medication as needed.  He denied any mechanical symptoms, and his symptoms were just pain and swelling.

The physical examination showed right and left knee without effusion, range of motion (ROM) to 135 degrees, and negative instability tests.  The right knee showed no joint line tenderness; however, the left knee showed mild lateral joint line tenderness, mild patellar crepitance, and mild patellar apprehension.

During the 10 October 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month prior to separation, the CI reported pain in both knees with residual aching and stiffness on a daily basis.  He no longer used a knee brace and he was taking Tylenol 1-2 tablets per month.  On examination, the CI walked with a normal gait.  Both knees revealed normal appearance without evidence of inflammation or swelling or tenderness.  He was able to squat and arise without discomfort.  He had full ROM of both knees (flexion to 140, and extension of 0) and painful motion was absent.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis).  Likewise, the VA assigned a 10% rating under the same coding scheme.  The approach by the PEB and the VA 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 this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.

Panel members considered the objective findings and associated disability for each knee were identical.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) and no evidence of painful motion with functional loss supporting a 10% rating for each knee (based on §4.59, §4.40 and §4.45). 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.  As mentioned above, the Board considered the bundling of the knees was permissible under the VASRD 5003 rating requirements, and, was appropriately used in this situation.  There was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

Left Ankle Pain, Paresthesia of Foot Status Post Tarsal Tunnel Releases.  According to the STR and the MEB NARSUM, the CI presented with the complaint of left foot pain in August 2000, after he injured his left foot in April 2000.  He reported he had pain along the inner side of his left leg, down to his ankle, followed by the development of a big bump on the inner ankle filled with fluid.  He was referred to podiatry in April 2001, at which time he was determined to have tarsal tunnel syndrome.  In May 2001 he underwent nerve conduction study after complaining of numbness in left foot and ankle, and was noted to have mild Tibial nerve compression with no evidence of nerve damage and intact sensory function.  The CI underwent left ankle/foot tunnel release surgery in June 2001.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2003, 8 months prior to separation, the CI reported numbness in the left foot and tingling sensation throughout the left leg.  He noted that he had occasional pain in the left foot at times to the extent of limping.  Physical examination noted decreased sensation in the sural nerve distribution of the left foot.

The 13 May 2003 MEB NARSUM podiatry addendum examination, 6 months prior to separation, noted complaints of left ankle pain secondary to surgery.  The CI reported he had significant pain while walking or running, and had developed significant swelling along the left bottom part of his foot.  He had shooting pain up his leg.

Physical examination showed tenderness to palpation along the posterior aspect of the left side of the ankle, and hypertrophic muscle along the left great toe region.  Ankle muscle strength was decreased 3/5.  The examiner recorded, “there was range of motion, which is guarded.”

At the C&P examination, the CI reported he had residual numbness in on the sole of his foot and in the great toe since surgery.  He noted that the numbness in his foot had improved, but he had persistent numbness in the medial aspect of the ankle just below the scar with pain shooting up his leg, usually aggravated by running.  Physical examination of the left ankle showed a well-healed medial malleolus scar, and no evidence of acute inflammation.  ROM recorded dorsiflexion to 20 degrees (20), plantar flexion to 45 degrees (45), and normal ROM in eversion and inversion.  All motions were noted as “painless.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 8799-8725 (neuralgia), rated as mild.  The VA assigned a 0% rating for the left ankle, coded analogously 5299-8622 (neuritis).  The panel noted that both the VA and PEB assessed his condition was mild.  The MEB physical examination recorded the finding of decreased sensation in the foot; however, ROM and gait were normal.  The VA examination was most proximate to separation, and that examination showed full ROM, absence of painful motion and a normal neurological examination.  Panel members agreed, at the time of separation his condition had improved significantly, and justification for a rating greater than 10% under any of the applicable nerve code was not justified, given evidence of impairment greater than mild was not present.  The panel noted the condition was not compensable under 5271 code (LOM), or 5272 code (subastragalar or tarsal joint, ankylosis of) or under the 5273 code (deformity, malunion).  The panel also considered foot codes 5276 (flat foot), 5279 (Morton’s disease), 5283 (tarsal or metatarsal bones, malunion of or nonunion of), and 5284 (foot injuries, other), and was unable to justified a rating under any of these codes.  The panel found no additional codes to consider.  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 left ankle condition. 

Contended PEB Conditions:  Left shoulder pain after surgery, pes planus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Although the left shoulder pain condition was listed on the permanent profile as U2 and implicated in the commander’s statement, it was not judged to fail retention standards.  The NARSUM physical examination showed tenderness to palpation of the shoulder joint, with no ratable ROM, and absence of evidence of neurological or motor impairment.  The pes planus condition was not profile or implicated in the commander’s statement or judged to fail retention standards.  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 chronic bilateral knee pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left ankle pain, paresthesia of foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left shoulder and pes planus conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150715, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011059, XXXXXXXXXXXXXXXXXX

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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,