RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-02140
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Patriot Launching Station Operator/Maintainer, medically separated for “chronic bilateral knee pain” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  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 - 20050901	VARD - 20060321	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Bilateral Knee Arthralgia	5099-5003	NSC	20060118	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating, analogously coded 5003 and rated 0%.  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 also noted that “bundling,” the combining of 2 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.  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.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary the bilateral knee condition began in late 2003 while performing physical training and road marches.  Physical examination showed normal knee range of motion (ROM) and was not remarkable for internal pathology.  The CI was given medications, duty limitations, and referred for physical therapy.  Over next 18 months, the CI was seen periodically for the knee pain and remained on profile.  The ROM remained normal until April 2005 when she was noted to have pain at the end of flexion, but still had full active ROM.  The CI was seen in orthopedics on 13 June 2005 which noted bilateral kneecap tenderness, but no effusion or documented meniscal pathology.  Bilateral knee X-ray taken that day were normal.  Patellofemoral syndrome (PFS) was diagnosed.

At the 2 August 2005 MEB NARSUM Orthopedics evaluation, 2 months prior to separation, the CI reported right greater than left knee pain aggravated by stairs, running, prolonged sitting, and walking.  The CI denied catching or locking, but reported subjective bilateral knee instability.  Physical examination revealed no right knee tenderness or instability.  Goniometric-measured flexion was 135 degrees (normal 140) and extension was 5 degrees (normal 0); painful motion was not addressed.  Left knee tenderness was present.  Goniometric-measured flexion was also 135 degrees but extension was 0 degrees; painful motion was not addressed.  The examiner noted the CI did not use any assistive walking devices, bilateral knees were stable, without signs of meniscal irritation, but bilateral kneecap grinding pain was present.

At the VA Compensation and Pension (C&P) evaluation performed on 18 January 2006, 3 months after separation, the CI reported moderate bilateral knee pain, occasional swelling, locking, stiffness, weakness, instability and endurance.  The CI denied any patellar dislocations or subluxations.  Physical examination showed a normal gait without pain, but also recorded a limp.  This inconsistency could not be reconciled.  Right and left knee motion was full and pain free.  The knees were stable, without signs of meniscal irritation, strength was full, and atrophy absent.  X-rays were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing no significant loss of motion.  The VA did not service connect the bilateral knee condition, also coded 5099-5003, based on the C&P evaluation 3 months after separation, citing no evidence of a current disability.  Panel members first considered if the knees were separately unfitting.  Both knees were treated by clinical visits, implicated by the commander as impairing duty, were profiled, and were found to be medically unacceptable.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bilateral knee condition were reasonably considered separately unfitting; and accordingly separate disability ratings are recommended.

There was no evidence of painful motion with ROM during the MEB NARSUM and VA examinations to support a 10% rating for functional loss (based on §4.59, §4.40 and §4.45).  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  While there was a non-compensable limitation in motion documented by the MEB NARSUM, the X-ray evidence was normal and painful motion absent; accordingly, a rating under 5003 (degenerative arthritis) is not supported.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove 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).  No additional functional limitation was evidenced by the examinations.  After due deliberation, and considering all of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20150806, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014669, 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,					      
						      					
Enclosure