RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00133
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060904

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Avenger Crewmember, medically separated  for “chronic bilateral knee pain from retropatellar pain syndrome with only the left knee unfitting” with a disability rating of 0%.   

CI CONTENTION:  The CI contends that he was given a higher rating for his conditions by the VA.   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 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 - 20060714	VARD - 20070607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain from Retropatellar Pain Syndrome with only the Left Knee Unfitting	5099-5003	0%	Left Knee Retropatellar Pain Syndrome	5260-5024	10%	20070202	
			Right Knee Strain	5260	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain from Retropatellar Pain Syndrome with only the Left Knee Unfitting.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in 1998 with running.  Radiographic (X-ray) studies showed a posterior medial meniscus tear.  The 14 October 2005 orthopedic evaluation, 11 months before separation, noted the knee was stable, there was no tenderness of the joint lines and there was no evidence of meniscal pathology.  There was full range of motion (ROM) with no pain with full flexion.  There was a positive patellar grind and pain in the patellofemoral joint.  The orthopedic specialist indicated that he did not think the pain was related to the medial meniscus and diagnosed chronic patellofemoral syndrome.  

At the time of the 2 November 2005 physical therapy evaluation, 10 months before separation, the examiner noted full left knee ROM with 10 degrees of hyperextension bilaterally.  There was positive patellar grind and tenderness of the patellar tendon.  At the 1 December 2005 physical therapy clinic visit, 9 months before separation, the physical examination showed a normal gait.  There was crepitus, and positive patellar compression test of the left knee, and minimal pain with testing for meniscal pathology.  

At the 9 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported that his “health was not good because of the condition of [his] left knee.”  Physical examination noted pain with palpation left greater than right, and the pain was increased with activity.  There was no swelling and the knee[s] were stable.  

The 15 June 2006 MEB Orthopedic NARSUM, 3 months prior to separation, the CI complained of 8/10 pain localized in the patella and infrapatellar area on both lower extremities, which was aggravated by running, prolonged marching and driving.  The physical examination (which did not indicate if it was of one or both knees) noted full ROM.  There was no evidence of instability or meniscal pathology, but there was a positive patellar grind.  

At the 15 November 2006 VA orthopedic evaluation, 2 months after separation the CI reported chronic left knee pain and swelling that prevented him from running or prolonged walking.  There was normal ROM, minimally tender joint lines and pain with testing for meniscal pathology.  The VA examiner noted the knee hyperextension and questioned knee instability, but a repeat magnetic resonance imaging (MRI) noted minimal joint effusion and was otherwise normal.

At the 2 February 2007 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported that he had 8/10 pain that was elicited by physical activity.  He reported knee swelling and stiffness and that he could not stand for long periods or run for long distances.  Physical examination showed normal gait and no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation or guarding of movement of the left knee.  Left knee ROM measurements showed a normal flexion of 140 degrees and a normal extension of 0 degrees, with crepitus.  The examiner indicated that the left knee joint was additionally limited after repetitive use due to pain, weakness, lack of endurance, and incoordination, but there was no additional loss of ROM.  There was no evidence of instability or meniscal pathology.  Left knee X-rays were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated chronic bilateral knee pain and indicated only the left knee was unfitting.  The PEB rated the condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing “full motion and good stability.”  It was rated for slight and occasional pain IAW the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA rated the left knee condition 10%, coded 5260-5024 (limitation of flexion due to tenosynovitis), citing “painful or limited motion of a major joint or group of minor joints.”  Additionally, the VA failed to service connect the right knee condition, citing no permanent residual or chronic disability subject to service connection was shown by the service medical records or demonstrated by evidence following service. 

The panel first considered if the both the left and right knees, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left knee was the only knee addressed at treatment visits in the STR.  The left knee was permanently profiled.  The commander’s statement did not implicate one or both knees as impairing the CI’s duty performance.  The MEB NARSUM noted bilateral knee pain but the examination addressed the knee, without specifying left or right.  The MEB DA Form 3947 listed recalcitrant retropatellar pain syndrome without noting right, left or both.  As noted above, the PEB Form 199 stated that “only the left knee unfitting.”  The panel concluded that the left knee was reasonably considered separately unfitting, but that the preponderance of the evidence did not support a conclusion that the functional impairment from the right knee condition was integral to the CI’s inability to perform his military duties, and accordingly cannot recommend a separate rating for it.  The panel then considered its rating recommendation for the unfitting left knee condition at the time of separation.

There was no evidence of painful motion with functional loss at the MEB NARSUM or post-separation VA examinations to support 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).  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), 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 therefore no higher rating available than 0% with any alternative VASRD code.  The panel noted that neither the PEB’s combined adjudication nor its reliance on the USAPDA pain policy was detrimental to arriving at the highest rating and no change to the PEB’s adjudication is recommended.  

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 condition.

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain 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 20160705, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170014066, XXXXXXXXXXXXXXXXXXX

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