RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02279
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060607

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Medical Specialist, medically separated for “bilateral knee pain” and “bilateral foot pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “Review of all conditions.”  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 progression or complications of service-connected conditions after separation.  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 - 20060502	VARD - 20070813	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Right Knee Strain	5260-5020	10%	20070511	
			Left Knee Strain	5260-5020	10%		
Bilateral Foot Pain	5399-5310	0%	Bilateral Plantar Fasciitis	5278	0%		
Left Shoulder Pain Secondary to Acromioclavicular Joint Degenerative Changes
and Supraspinatus Tendinopathy	Not Unfitting	Left Shoulder Strain with Degenerative Changes of the Acromioclavicular (AC) Joint (Non-dominant)	5201-5019	10%		
Right Wrist Pain		Right Wrist Condition (Dominant)	5215	NSC		
Subjective Neck and Upper Back Pain Without Contributory Findings		Cervical Strain	5237	10%		
Depressive Disorder		Mood Disorder Depression NOS (Not Otherwise Specified)	9435	30%	20070515	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:   The panel noted that treatment records relating to primary details of injuries sustained in the 2000 accident and subsequent follow-up visits were missing from the file.  Members discussed whether this negatively affected the panel’s ability to render a fair assessment; however, members agreed that the available evidence was sufficiently probative and the presumed missing documents would not materially affect the panel’s final recommendation.  However, records indicated the CI did not perform duty since 2001 and was transferred to the United States Army Reserve (USAR) Individual Ready Reserve (IRR) on 1 April 2002, 5 years before separation.

Bilateral Knee Pain Secondary to Retropatellar Pain Syndrome.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in May 2000 after he was hit by a car while on weekend drill.  Radiographic (X-ray) studies of the knees dated 12 October 2005, ordered for bilateral knee pain, demonstrated findings consistent with mild, early degenerative change with a lytic (breakdown) focus with a sclerotic (thickened) border in the medial epiphysis (end of the long bone) of the right tibia, most likely representing a subchondral cyst and mild osteophytosis (bony growths) at the left lateral tibiofemoral joint.   An orthopedic consultant briefly noted the left knee to be more involved than the right knee (overuse), the left knee “buckles,” and the CI had pain with running.  On examination there was medial joint line tenderness, +/- laxity, and a negative McMurray’s test (to determine a meniscal tear).

During the September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 11 months prior to separation, the CI reported pain in both knees and his left knee went out on occasion.  He had an occasional need for knee braces.  Physical examination showed tenderness to palpation bilaterally on the joint lines medially along with a positive grind test (to determine the presence of a patellofemoral joint disorder) bilaterally.  

The 11 January 2006 MEB NARSUM examination, 7 months prior to separation, noted complaints of constant dull left knee pain and right knee pain only with activity.  Pain was at a level of 2-3/10 with prolonged standing, walking, or running.  The pain improved with rest, heat and cold applications.  No surgery was recommended.  Physical examination showed the CI walked with a normal bipedal gait.  He had a full active range of motion (ROM) without effusion, joint line tenderness, or ligamentous laxity and had no varus or valgus instability of the right knee.  The left knee showed a mild effusion and a normal ROM.  There was crepitus with McMurray testing (to determine a meniscal tear), but no pain.  There was medial joint line tenderness, but no lateral joint line tenderness and no instability to varus and valgus stress.  The CI was unable to perform his Military Occupational Specialty (MOS), which required carrying a litter, performing a fireman’s carry, running, jumping, and marching for long distances.

At the 11 May 2007 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported weakness, swelling, and giving way with overuse, stiffness from inactivity, and locking and fatigability with use.   The pain level was 8/10, which was relieved by rest and medication including nonsteroidal anti-inflammatory drugs (NSAIDs) and knee wraps.  Physical examination showed signs of tenderness of both knees.  There was no recurrent subluxation, locking pain, joint effusion or crepitus (grinding sensation), and ROM measurements showed flexion of 130 degrees (normal 140) and a normal extension of 0 degrees for both knees.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral knee pain secondary to retropatellar pain syndrome condition 10%, coded 5099-5003 (arthritis, degenerative), citing degenerative joint disease with x-ray changes.  The VA rated the knee pain condition at 10% for the right knee and 10% for the left knee, coded 5260-5020 for each knee (limitation of flexion of leg and synovitis), citing painful motion.

Panel Approach to PEB Consolidated Rating. The PEB combined the bilateral knee pain conditions as a single unfitting condition coded 5099-5003 and rated 10%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  

The panel’s initial charge in this case was 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.  

The evidence for the bilateral knee pain conditions was presented together above.  In this case, the bilateral condition was profiled, and the bilateral knee pain condition was implicated by the NARSUM; however, there were no documents for the commander on which to base a Statement of Performance since the CI was assigned to the Individual Ready Reserve (IRR).  Members agreed that each knee condition is separately unfitting and that identical coding and ratings are applicable.  However, there was no evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) prior to separation, and while the VA finding of painful motion was at the end of motion for each knee that was 9 months after separation.  However, there was no evidence of accident, injury or surgery to account for those findings.  Furthermore, 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), or history of surgery to remove a 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.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than the 0% for either knee pain condition.  Therefore, the 10% rating adjudicated by the PEB based on X-ray evidence of involvement of 2 or more major joints was reasonable and appropriate since there was no evidence of any incapacitating episodes, which would have warranted a 20% rating.  

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 bilateral knee pain condition.  

Bilateral Foot Pain.  According to STR and the MEB NARSUM, the CI’s bilateral foot pain condition began in CI’s bilateral foot condition began in May 2000 after being hit by a car.  As a result of injuries sustained and limping, his right foot hurt.  X-rays of the ankles dated 12 October 2005 revealed a bilateral Achilles spur, a bilateral os trigonum (a congenital accessory bone that develops behind the talus), a right os supranaviculare (an accessory ossicle (very small bone) at the proximal dorsal aspect of the navicular bone), and probable bilateral pes planus.  Podiatric evaluation on 12 October 2005 indicated pain originated in the CI’s back as a result of sustaining multiple injuries and the pain went down to his feet.  On examination there was no gross deformity of the feet, but there was diffuse, mild tenderness to palpation of the left anterior ankle and plantar fascial band.  The ankle joint ROM was normal without crepitus and the subtalar joint was slightly restricted bilaterally without crepitus.  Mild pain with inversion bilaterally was also present.  The examiner’s diagnosis was “diffuse idiopathic foot pain, as possible sequelae of back injury” and plantar fasciitis.  Orthotics were ordered.

During the September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 11 months prior to separation, the CI reported pain in the left foot.  Physical examination noted decreased ROM left ankle.  A normal arch of the feet was circled on DD Form 2808.  

The 11 January 2006 MEB NARSUM, 7 months prior to separation, noted complaints of constant dull pain in his arches at a pain level of 3/10 that worsened to 8/10 with walking more than five blocks, running, or jumping.  Physical examination showed the CI walked with a normal bipedal gait.  Heel walking and toe walking were intact.  There was no gross deformity of the feet, but there was tenderness to palpation over the left anterior ankle and plantar fascial band.  Ankle joint ROM was normal without crepitus.  Subtalar joint motion was slightly restricted bilaterally without crepitus and there was mild pain with inversion bilaterally.  Sensation of the feet was intact bilaterally as were the dorsal pedis and posterior tibial pulses.  X-rays of the ankles and feet showed probable pes planus bilaterally.  No surgery was recommended.  

At the 11 May 2007 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported constant pain in the feet, which was worse with activity  and was relieved by rest, NSAIDs, soaking massage, and stretching.  Physical examination revealed tenderness of the left and right feet.  Neither pes planus, pes cavus, hammer toes, hallux valgus nor hallux rigidus were present.  The CI did not have any limitations and did not require any type of support with his shoes.  Non-weight bearing X-rays were within normal limits bilaterally.  

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral foot pain condition 0%, coded analogously as 5399-5310 (Group X. Function), citing the condition as slight.   The VA also rated the bilateral foot pain condition 0%, coded 5274 (claw foot (pes cavus), acquired), citing the evidence did not reflect severity of claw foot at the 10% level.    

Panel Approach to PEB Consolidated Rating. The PEB combined the bilateral foot pain conditions as a single unfitting condition coded 5399-5310 and rated 0%, presumably by combining a 0% rating for each foot condition since the 5310 code is a unilateral code as compared to code 5276 (flatfoot, acquired), which can be used for either a unilateral or bilateral condition. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  

The panel’s initial charge in this case was 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.  

The evidence for the bilateral foot pain conditions was presented together above.  In this case, the bilateral foot condition was profiled, and the bilateral foot pain condition was implicated by the NARSUM; however, there were no documents for the commander on which to base a Statement of Performance since the CI was assigned to the Individual Ready Reserve (IRR).  Members agreed that each foot condition is separately unfitting and that identical coding and ratings are applicable.  However, there was no evidence of painful motion with significant functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) prior to separation.  There was insufficient evidence to support either foot condition as moderate or more so in severity with the use of code 5399-5310.  Therefore, the panel members concluded there was not sufficient evidence to support a rating higher than the 0% for either foot pain condition.  Thus, the 0% rating adjudicated by the PEB was not inappropriate, albeit in fact the coding is better represented as 5399-5310 at 0% for each foot; however, that approach, although correct, does not offer any additional benefit to the CI.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral foot pain condition.  

Contended PEB Condition:  Left Shoulder Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The left shoulder pain was profiled; however, there were no documents for the commander on which to base a Statement of Performance since the CI was assigned to the Individual Ready Reserve (IRR).  Because of left shoulder pain, X-rays were ordered, which showed osteoarthritic change of the left acromioclavicular (AC) joint and an increased coracoclavicular distance (space between the clavicle and the coracoid process of the scapula) suggestive of an AC separation.  Evaluation by physical medicine on 9 November 2005 for pain over the left AC joint with episodes of intermittent numbness, tingling, and difficulty with abduction of the shoulder was noted to be present since the motor vehicle accident in 2000.   On examination the CI was tender over the AC joint in the vicinity of the coracoacromial ligament and had some tenderness in the supraspinatus tendon.  He also had a painful arc on abduction.  Neurological evaluation of the left upper extremity was unremarkable.  Electrodiagnostic studies of the biceps, triceps, and deltoid muscles of the shoulder were normal.  The examiner summarized the findings as a strain/tear to the left coracoacromial ligament, left impingement syndrome, and a possible very mild cubital tunnel syndrome (not in the scope of review), that may be the cause for the intermittent vague numbness and tingling complaints.  The NARSUM examiner noted moderate tenderness to palpation over the AC joint on the left.  The CI had mild pain with cross body adduction test (to determine AC joint injury/pathology), while other tests of shoulder function impairment (Hawkins sign, apprehension test, load and shift test and impingement sign) were negative.

There was no performance-based evidence from the record that left shoulder condition 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 the left shoulder pain contended condition; and so, no additional disability ratings is recommended.  

Contended PEB Conditions:  Right Wrist Pain, Subjective Neck and Upper Back Pain and Depressive Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement nor 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 bilateral knee pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral foot pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended left shoulder pain, right wrist pain, subjective neck and upper back pain, and depressive disorder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.   The panel, therefore, recommends that 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 20150824, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012171, 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,