RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-02182
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070309

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E6, Air Traffic Control Operator, medically separated for “chronic bilateral knee pain” with a disability rating of 0%.  

CI CONTENTION: “Chronic knee pain; inability to perform any impact activity.”  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.  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 - 20070221	VARD - 20041116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Residual, Status Post left ACL and Lateral Meniscal Repair with Chondromalacia	5299-5262	10%	20041029	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain, Left Greater than Right.  The PEB combined the left and right knee conditions as a single, bilateral unfitting condition coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency (USAPDA) 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 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.  

According to the service the treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in July 2001 after falling while playing sports in physical training.  Her right knee began experiencing pain in 2005 after several years of favoring her left knee when walking or standing.  She deployed to Afghanistan and Kosovo between 2002 and 2004.  An MRI was done in November 2001 but she reported that she did not find out about the results until July 2002 (upon her return from Kosovo).  The MRI was abnormal showing a torn meniscus and ACL.  She underwent a total of five knee surgeries on her left knee to include December 2005 (ACL reconstruction and lateral meniscus repair); and, March 2004 (hardware removal).  She was evaluated by orthopedics at Fort Bragg in August 2005 where a radiographic finding revealed an “incompetent ACL reconstruction and reconstruction and recurrent tear involving the lateral meniscus.”  Her third left knee surgery was done at Fort Bragg in October 2005 where she underwent a revision ACL reconstruction and bone grafting of both tibial and femoral tunnels and subtotal medial and lateral meniscectomies.  Additionally she had a fourth left knee surgery, another revision ACL and lateral meniscal transplant and finally her fifth left knee surgery, lateral meniscal transplant was completed in July 2006.  

During the 13 December 2006 MEB NARSUM examination, 3 months prior to separation, the CI reported constant daily bilateral knee pain with the left knee varying from 2-3/10 at rest to 5-6/10 with activity.  Right knee pain was generally less.  The examiner noted that the CI walked with a slight limp.  Her left knee showed no erythema or edema.  There was slight atrophy of the quad muscles in the quad tendon area.  She had multiple (6) healed scars around the left knee but none were noted to be tender.  There was negative Lachman’s and McMurray’s and there was slight limitation of movement noted.  The right knee was reported as stable with no erythema, edema or atrophy.  There was positive patellar facet tenderness but there was a positive patellar grind test.  There was no joint line tenderness, negative Lachman’s and McMurray’s tests and no limitation of movement.  Her range of motion (ROM) was essentially normal for both her left and right knees.  

At the 29 October 2004 VA Compensation and Pension (C&P) evaluation, 13 months after separation, the CI reported that she was a full-time student.  She stated that neither knee condition appreciably interfered with her work as a student.  She stated that her (left) knee was painful on an average of once weekly with the pain 8/10 in intensity and lasting as long as 1-2 days.  She reported the pain was aggravated mainly by standing, stairs and long walking.  The examiner noted a normal gait, no locking or giving way, and no required assistive devices such as braces.  There were no ROM measurements in the examination record or narrative.  The panel could not find evidence in the commander’s statement, profile or elsewhere in the STR that indicated the right knee caused any significant interference with the performance of duties.  Therefore, the panel concluded that the preponderance of evidence showed the right knee condition would not reasonably have caused the CI to be referred into the DES or be found unfit.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded analogously 5099-5003 (degenerative arthritis), citing the USAPDA pain policy.  The VA rated only the left knee as “residuals, status post left ACL and lateral meniscal repair with chondromalacia” rated 10%, coded analogously 5299-5262 (tibia and fibula impairment of) citing “malunion of the tibia and fibula with slight knee disability.”  There was a history of surgery to remove a meniscus (5259) to support a 10% rating.  There was no limitation of motion which attained a minimum 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).  There was therefore no VASRD §4.71a route to a higher rating under any applicable code, and no grounds for additional rating based on the presence of instability.  There was no fracture, nonunion, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  

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 condition, coded 5259.  The panel determined that the right knee was not unfitting and therefore recommends no rating for the right knee condition.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain condition, the panel unanimously recommends a disability rating of 10% for the left knee only, coded 5259 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Knee Pain	5259	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150809, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010291, 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