RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02456
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated for “bilateral retropatellar pain syndrome, right greater than left,” with a disability rating of 0%.

CI CONTENTION:  The CI requested a review of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 Board’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 Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’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 Board 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 Board 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 - 20020911	VARD - 20030123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Retropatellar Pain Syndrome, Right Greater Than Left…	5099-5003	0%	Medial Meniscus Tear and Anterior Cruciate Ligament Sprain, Right Knee 	5299-5260	10%	20021015	
			Retropatellar Pain Syndrome (RPPS), Left Knee	5299-5260	10%	20021015	
Mechanical Low Back Pain	Not Unfitting	Degenerative Disc Disease L4-5 and L5-S1, Lumbar Spine	5293-5292	10%	20021015	
Reactive Airways	Not Unfitting	Exercise-Induced Asthma 	6602	10%	20021015	
Chronic Dermatitis	Not Unfitting	Dermatitis of the Toes	7806	NSC	20021015	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Retropatellar 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 Board 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 Board’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 Board 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 Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began on or about November 2001 with the right knee injured first when performing physical training and the left knee developing afterwards.  Radiographic studies showed evidence of Osgood-Schlatter's and a right medial meniscal deterioration and anterior cruciate ligament sprain.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “bilateral knees: anterior knee pain syndrome” for PEB adjudication.  At the MEB Board Consult examination on 9 July 2002 (4 months prior to separation), the CI reported intermittent recurrent effusions of both knees with increased activity.  Her knee pain prevented her from running, standing greater than 30-45 minutes per hour, doing any squatting, jumping or prolonged sitting secondary to anterior knee pain. The physical examination of both knees showed no effusion.  Tenderness and patellar grind were present.  Bilateral knee flexion was 120 degrees (normal 140 degrees) and extension was 0 degrees (normal 0 degrees).  She had hypermobile patellae bilaterally.  She had no laxity with varus or valgus stress. There was a 1+ Lachman's and anterior drawers bilaterally with a solid endpoint. There was a negative posterior drawer bilaterally.  At the MEB NARSUM examination on 27 August 2002 (3 months prior to separation), the CI reported pain aggravated by running or jumping, standing or sitting in one position for more than 30 minutes, or squatting, kneeling, or crawling.  Tenderness and patellar grind were present.  Bilateral knee flexion was 142 degrees (normal 140 degrees) and extension was 0 degrees (normal 0 degrees).  There was no instability, laxity, or Murray's.  At the 15 October 2002 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported her knees interfered with her ambulation, she was only able to walk about 1/4 mile and had problems bending on the knees.  Right knee flexion was 120 degrees (normal 140 degrees) and extension was 0 degrees (normal 0 degrees).  There was bilateral laxity but no instability.  However, the examiner noted that it was difficult to evaluate the right knee when it came to the Lachman's and McMurray's tests, “because any kind of a stress applied even to the moderate stress testing with three repetitions complained of a diffuse pain, but whatever best I could find, there was no evidence of any locking, in other words, no typical evidence of any locking if the knee and the medial joint line on the right did cause pain.”  Measurements for left knee flexion was 130 degrees (normal 140 degrees) and extension was 0 degrees (normal 0 degrees).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (degenerative arthritis), citing degenerative arthritis without X-ray changes.  The VA rated each knee condition 10%, coded 5299-5260 (limitation of flexion of leg), citing pain on some limited motion, based on the pre-separation C&P examination.  The Board first considered if each knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Members agreed member consensus was therefore that each knee is separately unfitting and that identical coding and ratings are applicable.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 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) 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).  A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the NARSUM and VA C&P examinations provided satisfactory evidence for painful motion of both knees; thus, separate joint ratings are indicated IAW §4.71a.  After due deliberation, and considering all of the evidence, the Board recommends a disability rating of 10% for the right knee condition and 10% for the left knee pain condition, coded 5099-5003.  

Contended PEB Conditions:  Mechanical Low Back Pain, Reactive Airways, and Chronic Dermatitis.  The Board’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 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 Board 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 condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended mechanical low back pain, reactive airways, and chronic dermatitis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board 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	
Right Retropatellar Pain Syndrome	5099-5003	10%	
Left Retropatellar Pain Syndrome	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151013, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004628, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

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