RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02593
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Multichannel Transmission Systems Operator, medically separated for “chronic bilateral knee pain” with a disability rating of 10%.

CI CONTENTION:  “Department of Defense rated lower than required per schedule of rating disabilities used by Department of Veterans Affairs.”  The CI’s 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 conditions 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 - 20051103	VARD - 20070726	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Left Knee Pain	5299-5257	NSC	STR	
			Chondromalacia Left Patellae	5299-5257			
			Right Knee Pain	5299-5257			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in February 2003 after road marching during Basic Training.  A note dated 10 December 2004 indicated the CI had left knee pain since Basic Training.  Computerized tomography (CT) showed a well-circumscribed lesion of the distal posterior medial aspect of the femur, but she had pain anteriorly at a certain flexion angle when load bearing.  Treatment consisted of naproxen, a nonsteroidal anti-inflammatory drug (NSAID) for chondromalacia patella (inflammation and softening of kneecap cartilage) of the left knee.  

Magnetic resonance imaging (MRI) studies of the knees dated 11 March 2005 showed chondromalacia patellae of the lateral facet of right knee where a large piece of cartilage was suggested to have been lost inferiorly along with a likely nonossifying fibroma, while the left knee had mild to moderate chondromalacia of the lateral patellar facet.  CT scanning of the left femur on 23 March 2005 showed a probable benign expansible bone lesion of the distal left femur.  The differential diagnosis included a nonossifying fibroma, chondrosarcoma, and a localized fibrous dysplasia.  Chondroid tumors, histiocytosis and other lesions could also have that appearance.  There was also mild lateral displacement of the left patella in comparison to the right side.  The radiologist recommended close follow-up examination and doubted the knee symptomatology resulted from the lesion.  Orthopedic evaluation on 23 March 2005 noted bilateral pain with patellofemoral compression and bilateral anterior lateral joint line tenderness.  Continued physical therapy and NSAIDs were recommended.  

During 11 May 2005 the MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported knee inflammation and pain that was severe at times.  Physical examination showed tenderness with movement and palpation of the left knee.  The examination was silent in regard to the CI’s right knee condition.  At an orthopedic oncology visit on 3 June 2005 the examiner felt the lesion of the left femur was incidental since it had discrete, well marginated borders without a periosteal reaction and was non tender.  The examiner also noted the CI had medial joint line tenderness with a history of occasional locking and giving way consistent with a medial meniscal tear.  At a Troop Medical Clinic visit, Feldene (piroxicam, an NSAID) was prescribed instead of the naproxen.  A bone scan dated 8 June 2005 showed a small focal abnormality of the left distal femur with a pattern more consistent with a benign process than a malignancy.  On 18 July 2005 the CI reported she was pain free, but was unable to walk without a cane.  The CI noted on 27 July 2005 the left knee pain was exacerbated a week earlier, but on examination there was no warmth or laxity, but there was some pain with palpation at the lower portion.  
 
The 18 August 2005 MEB NARSUM, 3 months prior to separation, noted complaints of constant pain in the knees, the left greater than right, which she rated at 5/10 (10 being the worst pain).  The examiner recorded that the “Orthopedic Surgeon felt that this [CI] would never be able to adapt to the rigorous demands of the Army conditioning program.”  Physical examination of the left knee showed limitation of flexion to 120 degrees (140 normal) with pain starting at 90 degrees.  No extension measurement was listed.    There was medial joint line tenderness, a mild effusion, mild crepitus, and a positive patellar grind test of the left knee.  Physical examination of the right knee showed limitation of flexion to 120 degrees with pain starting at 110 degrees and there was no extension measurement listed.  There was moderate tenderness, minimal crepitus, and a positive patellar grind test on the right.  However, there was no effusion and examination testing for ligamentous instability was negative for the right knee.  The CI’s gait was slightly antalgic and she had difficulty transitioning from sitting to standing.

The commander’s statement of 14 September 2005 indicated that the CI was “physically incapable of performing the duties of a Multichannel Transmission Systems Operator Maintainer due to bilateral knee pain, chondromalacia patella.”  The L3 profile for bilateral knee pain and chondromalacia patellae, dated 28 October 2005, indicated that CI couldn’t wear a rucksack or Kevlar and could not run, jump, perform impact exercises, lift over 30 pounds,  carry 30 pounds more than 20 feet, or stand for over 10 minutes at a time.  However, the CI could pass the Army Physical Fitness Test (APFT) by performing an alternate APFT event.

There was no VA examination proximate to separation.  A remote VA Compensation and Pension examination was performed on 5 March 2008, which had no probative value to the rating at the time of separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee conditions together at 10%, coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA did not service connect the bilateral knee condition, analogously coded 5257 (knee, other impairment of) for each, citing “no evidence the claimed condition exits.”  

The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5003 and rated 10% with application of the 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 evidence for the bilateral knee conditions were presented together above, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated, will be discussed below.  

The panel first considered whether the left and right knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel majority concluded that there was a preponderance of evidence that each knee was separately unfitting.  The panel then considered its rating recommendation for the unfitting left and right knee conditions at the time of separation.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261) for either knee.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257) in either knee, 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) in either knee to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration of either knee under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for both the left knee and right knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the left knee condition coded 5099-5003 and a disability rating of 10% for the right knee condition coded 5099-5003. 

BOARD FINDINGS:  In the matter of the left knee condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right knee condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent recommends no re-characterization and elected not to submit a minority opinion.  There were 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	
Left Knee Pain	5099-5003	10%	
Right Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150623, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Rating Decision

AR20170013339, 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