RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02416
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060513

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Fire Support Specialist, medically separated for “chronic bilateral knee pain” with a disability rating of 0%.  

CI CONTENTION:  “Please consider 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 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 - 20060215	VARD - 20061130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Left Knee Retropatellar Pain Syndrome	5099-5024	10%	20060928	
			Right Knee Retropatellar Pain Syndrome		10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 and rated 0%.  The 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.  The evidence for the right and left knee conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic bilateral knee pain condition began in November 2004 after engaging in strenuous activity and running.  Right knee pain increased after being run over by a 3-wheeled motorcycle in April 2005.  Radiographic studies showed some medial compartment narrowing but no other abnormality.  

During the 26 October 2005 MEB examination (recorded on DD Forms 2807-1 and 2808) 7 months prior to separation, the CI reported bilateral knee pain for which he wore knee braces and orthotics in his shoes.  The pain was increased by running, jumping, walking and marching long distances.  Physical examination showed full active range of motion (ROM) without crepitus, tenderness to palpation (TTP) or compression.  The 24 November 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of bilateral knee pain.  The physical examination showed full ROM and mild TTP of both knees.  Both knees were negative for meniscal damage. 

 At the 28 September 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported  that he did not miss time from work and was able to perform his duties as a truck driver.  However, he did complain of soreness and stiffness of his knees but it was relieved with use of ice or heat packs and over-the-counter pain medications.  The physical examination showed some tenderness with compression over the patella but no gross tenderness or swelling.  Range of motion was recorded as flexion to 145 degrees (normal 140) bilaterally and extension to 0 degrees (normal).  The examiner noted no painful motion.  The examiner opined that “it is within reason to believe that this patient would lose between 0 and 5 degrees of his range of motion, strength, coordination, and fatigability associated with repetitive movement flares.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee pain condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing normal gait, full ROM and some pain and crepitus.  The VA rated the left and right knee 10% each coded 5099-5024 (analogous to tenosynovitis), based on the VA C&P examination 4 months after separation, citing the examiners opinion that the CI could lose up to 5 degrees of ROM due to weakness, fatigue or incoordination during a repetitive movement flare.  

The panel agreed the commander’s statement, profile and the majority of the clinical notes implicated both knees equally.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with military occupational specialty performance, the members agreed that each knee was reasonably justified as separately unfitting.  There was no limitation of motion in either knee which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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, 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).  No additional functional limitation was evidenced by the examinations.  There was no evidence of painful motion with functional loss supporting a minimum rating (based on §4.59, §4.40 and §4.45).  There was evidence of medial compartment narrowing on plain film X-rays (evidence of arthritis).  The description under VASRD code 5003 states ”When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10% is for application for each such major joint.”  

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 each knee, coded 5003.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends a disability rating of 10% for each knee, coded 5003 for a combined rating of 20% IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that 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 Right Knee Pain	5003	10%	
Chronic Left Knee Pain	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140715, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012894, 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 and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,	
Enclosure