RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02491
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a activated National Guard E2, Infantryman, medically separated for “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 - 20041202	VARD - 20050622	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Patellofemoral Syndrome, Right Knee	5099-5003	10%	20050511	
			Patellofemoral Syndrome, Left Knee	5099-5003	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition began in June 2003 when the CI injured his right knee after falling during a training exercise.  The left knee injury began in 2004 during mobilization activity.  

At the time of the 4 May 2004 primary care clinic appointment, 8 months prior to separation, the examiner recorded that the CI had moderate abnormal liquid buildup in the right knee, with pain behind the patella, but the anterior cruciate ligament (ACL) appeared normal.  The left knee also had moderate abnormal liquid buildup, without pain around the patella, and no evidence of torn or ruptured ligaments.  The CI exhibited a normal gait.  

During the 23 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported chronic right knee pain with swelling and giving out.  Physical examination showed the right knee without gross effusion.  There was pain on motion and pain with squatting.  

The 22 September 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of persistent pain and swelling in the CI’s right knee.  The CI described his pain as a dull aching in the front of the knee, which worsened with prolonged sitting, standing, road-marching, and running.  Right knee radiographic (X-ray) studies in April 2004 were normal, and magnetic resonance imaging (MRI) showed a bone contusion involving the patellofemoral joint.  Physical examination showed the CI had mild right knee swelling, and tenderness over the front of the knee.  Testing revealed no signs of meniscus pathology, no instability, and no ligamentous laxity.  There was no mention of a left knee condition at the NARSUM examination; however, range of motion (ROM) was recorded for both knees with a flexion of 125 (normal 140) and a normal extension of 0 degrees.  

At the 11 May 2005 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported that both knees swelled, there was popping sound, and pain was constant, particularly during sleep.  X-rays of both knees were normal.  Physical examination showed that there was tenderness in the front of both knees.  Testing of the ligaments and meniscus were normal, and neither knee demonstrated grating/popping sounds, or abnormal liquid buildup.  ROM measurements of both knees showed a flexion of 135 degrees and a normal extension of 0 degrees, there was painful motion and additionally limited by pain on each side, but not by fatigue, weakness, lack of endurance, or incoordination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 VA separately rated the right knee condition 10%, and the left knee condition 10%, each analogously coded 5003 (arthritis, degenerative), citing painful or limited motion for each knee.  

The panel first considered whether the right knee condition, when considered alone separate from the left knee condition, was unfitting for continued military service.  The evidence makes clear that the right knee condition was associated with more disability than the left knee in this case.  Members agreed that the right knee condition was reasonably justified as separately unfitting.  Accordingly, the right knee condition should be afforded separate service disability rating.  

The panel next considered whether the left knee condition, when considered alone separate from the right knee condition, was unfitting for continued military service.  The left knee was profiled (bilateral knee pain) and noted to fail retention standards by the MEB, however, the left knee was not implicated in the commander’s statement. The MEB examination or the NARSUM.  Panel members agreed that there was a preponderance of evidence in the STR that overcame the presumption that the left knee condition was reasonably considered separately unfitting.  Accordingly, the left knee condition was adjudged as not separately unfitting or ratable.  

The panel discussed the probative value of the disparate examination in evidence.  The NARSUM examination did not address repetitive motion or DeLuca criteria, while the MEB examination showed painful motion.  The VA examination was proximate to separation, addressed DeLuca criteria, and documented painful motion.  Given the MEB examination evidence of painful motion, the panel adjudged that the MEB examination and VA examination best aligned with the preponderance of the STR and had the highest probative value for rating at separation.  

For the right knee condition, there was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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).  

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 right knee condition coded 5099-5003 and no separate rating for the left knee pain condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the panel unanimously recommends that the right knee pain condition be found separately unfitting coded 5099-5003 and rated 10%, IAW VASRD §4.71a; and that the left knee pain condition be found not unfitting or ratable.  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	
Right Knee Pain	5099-5003	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150331, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013258, 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