RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00094
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030513

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistics Specialist, medically separated for “chronic pain, bilateral knees and ankles,” with a disability rating of 10%.  

CI CONTENTION:  “The severity of my condition should have afforded me the opportunity to be medically retired. Review 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 - 20030310	VARD - 20031030	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Bilateral Knees and Ankles	5099-5003	10%	Tendonitis, Right Knee with Degenerative Joint Disease	5299-5003	0%	20030812	
			Tendonitis, Left Knee	5299-5024	0%	20030812	
			Tendonitis, Right Ankle	5271-5024	0%	20030812	
			Tendonitis, Left Ankle	5271-5024	0%	20030812	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Pain, Bilateral Knee and Ankles.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee and ankle pain condition began in September 2001 without specific injury.  Evaluation by orthopedics in April 2002 concluded with a diagnosis of posterior tibial tendinitis, both ankles, and he was further diagnosed with bilateral tenosynovitis in his knees in September 2002.  Ankle X-rays were normal; ankle magnetic resonance imaging (MRI) showed a right osteochondral defect of the medial talar dome, and was otherwise unremarkable.  The CI was treated with duty limitations, medications, injections, and physical therapy.  There was no surgical indication.  

The 9 January 2003 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain in both knees and ankles, especially when the CI had to walk “quite a bit.”  Physical examination showed tenderness behind the medial malleolus over both ankles and tenderness of the plantar surfaces of both feet with a normal arch.  The CI was wearing tennis shoes with foot inserts with both shoes. On examination, the left/right knee range of motion (ROM) following repetitive movement was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal 0) respectively.    On examination the left/right ankle range of motion (ROM) following repetition showed dorsiflexion of 10/15 degrees (normal 20 degrees) and plantar flexion of 50/50 degrees (normal 45 degrees).   

At the 12 August 2003 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported mild (6/10) pain in both knees and ankles about once a week, worse when standing for an hour, walking three miles, or in cold weather.  There was no complaint of weakness, stiffness, swelling, heat, redness, or locking.  Physical examination showed “no swelling, no heat, no redness, and no loss of motion or function.”  Both knees had full ROM with no pain, and ankles had full ROM.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right knee and left knee and right ankle and left ankle conditions under a single service disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  This 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 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 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 rated each knee and ankle joint separately at 0% each coded analogously to 5003 for the right knee and analogously to 5024 (tenosynovitis) for the left knee and each ankle, based on the C&P examination 3 months after separation, citing degenerative changes in the right knee and no loss of motion or function and no pain at the time of the examination for each knee and normal ROM of both ankles with no objective evidence of pain on motion or function loss for either ankle.  In this case, all four joints were considered to fail retention standards; all four joints were implicated by the NARSUM and all were profiled.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee or ankle.  Since undue speculation would be required to conclude that impairment from either knee or either ankle would not have unacceptably interfered with MOS performance, members agreed that each knee and each ankle was reasonably justified as separately unfitting.  

The panel then considered its rating recommendation for each knee and each ankle condition at the time of separation.  There was no VASRD-compliant mechanism for rating either knee separately at higher than 0%.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion 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, 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.  There was evidence of limited motion of the ankles at the NARSUM examination, and there was no limited ankle ROM by the time of the post-separation C&P examination.  No examination documented painful motion of either ankle.  The NARSUM’s limited ankle ROM was the single examination in evidence which documented left ankle dorsiflexion limited to 10 degrees (normal 20) which would warrant a 10% rating for “moderate” limitation analogous to code 5271 (ankle, limited motion); while the right ankle’s limitation of 15 degrees dorsiflexion would rate 0% IAW VASRD §4.31 (a no-percent rating) for slight limitation.  Given that only the left ankle (of all of the PEB-bundled joints) could be separately rated at 10%, there was no benefit to alternatively coding and rating each of the bundled joints, as unbundling the four joints and rating them separately would not be of benefit to the CI, and would not provide a combined rating higher than the 10% awarded by the PEB.  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 and ankle condition.  

BOARD FINDINGS:  In the matter of the bilateral knee and ankle pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20160225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013350, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure