RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00171
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050524

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

CI CONTENTION:  The CI requests 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 - 20050407	VARD - 20060127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	10%	Strain and Osgood-Schlatter Disease, Left Knee	5014-5260	10%	20050713	
			Strain and Osgood-Schlatter Disease, Right Knee	5014-5260	10%	20050713	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Bilateral Knees.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 and rated 10%.  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.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in October 2001, during Ranger School after a traumatic landing of an airborne operation.  Radiographic studies of the right knee was normal, and the left knee showed a probable un-united tibial epiphysis.  Radiographs were interpreted as consistent with Osgood Schlatter (tibial tubercle) disease.  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 over the other.  Since undue speculation would be required to conclude that the impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.  

In October of 2004, the CI was seen for the knee pain and was diagnosed with Osgood-Schlatter disease.  At the 13 January 2005 MEB NARSUM examination, 4 months prior to separation, the CI reported chronic knee pain that did not allow him to conduct his duties as an infantryman.  The MEB physical examination of both knees noted prominent and tender tibial tuberosity on each side, with no swelling or effusion.  Meniscal signs were absent.  The range of motion (ROM) of each knee was mildly limited in flexion to 125 degrees (normal 140) following repetitive movement, with normal extension of 0 degrees.  

At the 13 July 2005 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported that pain was aggravated by prolonged standing, riding bicycle, walking over a mile, going up and down stairs, sitting too long, lifting and walking on the treadmill.  Physical examination showed a normal gait, with no tenderness, deformity, or painful motion.  The ROM of each knee was mildly limited in flexion to 130 degrees on the right and 135 degrees on the left (normal 140) following repetitive movement, with normal extension of 0 degrees bilaterally.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded analogously to 5003 (arthritis, degenerative), citing his physical examination and ROMs.  The VA rated the left knee and right knee conditions 10% each, coded 5014-5260 (osteomalacia - leg, limitation of flexion), based on the post-separation C&P examination.  Panel members considered that the objective findings and associated disability for each knee were identical, and agreed that the respective ratings should therefore be the same.  There was evidence of tibial impairment for analogous coding under 5262 (tibia and fibula, impairment) for each knee.  The panel concluded that there was sufficient evidence of functional loss to support a 10% (slight knee disability) rating for each knee IAW §4.59 and §4.40.  In considering routes to a higher rating however, there was no limitation of motion which attains a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (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 to support consideration under code 5255 (impairment of the femur).  

After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right knee pain condition and 10% for the left knee pain condition, each coded 5299-5262.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5299-5262and rated 10%, and an unfitting left knee condition coded 5299-5262 and rated 10%, both IAW VASRD §4.71a.  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	
Strain and Osgood-Schlatter Disease, Left Knee	5299-5262	10%	
Strain and Osgood-Schlatter Disease, Right Knee	5299-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160326, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014096, 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