RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00374
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060301

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Telecommunications Operator/Maintainer, medically separated for “bilateral knee pain” with a disability rating of 0%.  

CI CONTENTION:  “Continued problems with my knees, constant pain.”  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 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 - 20060103	VARD - 20070814	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Retropatellar Syndrome of the Right Knee	5260	0%	20060919	
			Retropatellar Syndrome of the Left Knee	5260	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the bilateral knee pain conditions under a single 0% disability rating, coded analogously to 5003 with application of the USAPDA pain policy AR 635-40 B24.f.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows individual ratings for each compensable joint in accordance with §4.7 (higher of two ratings).  The panel must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the panel judges that the bundled conditions are reasonably justified as separately unfitting, then separate ratings are recommended; with the stipulation that the result may not be lower than the combined rating from the PEB for the bundled conditions.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the bilateral knee pain conditions are presented; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral knee condition began in 2003 while deployed to Afghanistan, after she fell during a run.  Radiographic studies of the bilateral knees showed no evidence of fracture, dislocation, effusion, arthritic changes or other significant abnormalities in February 2003 (X-ray) and a normal right knee in September 2005 (MRI).  The 17 October 2005 Commander’s statement attributed physical limitations to the bilateral knees.  

During the 27 October 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported pain, use of bilateral knee braces, locking, and giving out when running, standing, and sitting.  Physical examination showed mild pain while stressing the right knee.  There was no effusion, swelling, instability, or laxity of either knee.  There was a normal heel and toe walk, however, bilateral knee pain occurred with full squat and duck walk.  At the 1 November 2005 physical therapy visit, 4 months prior to separation, range of motion (ROM) measurements showed right knee flexion of 135 degrees (normal 140) and left knee flexion of 125 degrees.  Both showed normal extension (normal 0).  Pain was not addressed.  At the 7 December 2005 MEB NARSUM examination, 3 months prior to separation, the CI reported “intermittent” pain with swelling after exercise such as walking or climbing stairs.  She also reported 4 or 5 episodes of giving way of the right knee that caused a fall while running.  The examiner documented the examination from the October 2005 DD Form 2808 and referenced the November 2005 PT ROM measurements.  An 8 December 2005 profile delineated limitations for the “chronic bilateral retropatellar pain.”  

At the 19 September 2006 VA Compensation and Pension (C&P) evaluation, 7 months after separation, the CI reported intermittent bilateral knee pain, right worse than left, occurring “a couple of times a week, lasting 10 minutes.”  She also reported instability and weakness, and has fallen “a couple of times” in the past, however, denied that the condition affected her job.  Physical examination of both knees showed no evidence of edema, effusion, abnormal movement, guarding, instability, laxity, or tenderness.  There was a normal gait, and ROM measurements for both knees were normal, with no pain reported.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing near normal ROM, no joint laxity or swelling, negative imaging, and a pain rating for ‘minimal and frequent’ IAW the US Army Physical Disability Agency pain policy (AR 635-40).  The VA individually rated 0% for each knee condition, identically coded as 5260 (leg, limitation of flexion), citing no objective evidence relating to her knee condition.  The panel first considered if the right and left knee pain conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards, both were implicated by the NARSUM and the commander’s statement and both were profiled.  The panel concluded that there was a preponderance of evidence of the service records that overcame the panel’s presumption that the bundled knee condition is reasonably considered separately unfitting.  The panel then considered the rating recommendation for the unfitting right and left knee conditions at the time of separation.  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 limitation of flexion or extension that supported a higher rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no history or evidence 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 those codes.  There was no fracture, nonunion 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 and 10% for the left knee both coded 5260.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the panel unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 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	
Left Knee Pain	5260	10%	
Right Knee Pain	5260	10%	
COMBINED w/BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160606, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015441, 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