RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00382
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Unit Supply Specialist, medically separated for “bilateral knee pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends her knees continue to worsen and negatively impact daily activities, and also for conditions not identified by either the MEB or PEB.  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 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 - 20020208	VARD - 20030317	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain…	5003	10%	Left Knee Patellar Chondromalacia and Tendonitis	5099-5014	10%	20030220	
			Right Knee Patellar Chondromalacia and Tendonitis	5099-5014	10%	20030220	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the bilateral knee pain conditions as a single unfitting condition coded 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 service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in November 1997 without specific injury.  Radiographic studies in April 2001 showed bilateral degenerative joint disease.  There was no surgical indication.  The MEB NARSUM, 10 January 2002, noted that the CI reported aching every day so severely that it interfered with her sleep.  The ache was aggravated by running and walking any significant distance.  Also pushing and pulling of furniture and heavy items as a normal part of her job aggravated her knees.  Cold weather also caused extreme aggravation.  Sitting too long also caused her knees to stiffen up and ache.  Sitting in a military vehicle likewise aggravated her knees, as she could not stretch and find a position of comfort.  The MEB physical examination noted the CI was tender to palpation over both kneecaps and had a positive patellar grind test.  There was full range of motion (ROM) of the knees with good strength. 

At the 20 February 2003 VA Compensation and Pension (C&P) evaluation, performed 11 months after separation, the CI reported pain and stiffness as well as inability to run and inability to climb up stairs without significant pain.  She had had a couple of injections in each knee, both of which helped for about 1 week and then her normal pain returned.  She reported giving way of her knees, but no locking.  Physical examination showed a normal gait.  Both knees showed crepitus. Both were tender to palpation.  Both had no effusion.  Both knees were neurovascularly intact distally, and both were stable to anterior/posterior and varus/valgus stresses.  She had 5/5 strength of all major muscle groups on the right and left.  On examination the right knee ROM following repetitive movement was flexion 140 degrees (normal 140).  The knee hyperextended to 10 degrees (normal extension is 0 degrees).  The left knee produced the exact same results as the right. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee pain condition 10%, coded 5003 (degenerative arthritis), citing osteoarthritis with x-ray evidence of degenerative changes, without loss of range of motion or joint instability.  The VA rated the each knee pain condition 10%, coded analogously as 5099-5014 (osteomalacia), citing (for both knees) crepitation upon motion and, painful motion with objective evidence of joint disease. 

Panel members considered that the objective findings and associated disability for each knee were identical with minimal pathology.  The panel majority concluded there was insufficient evidence to support that the impairment from either knee would have unacceptably interfered with MOS performance, and therefore, agreed, the PEB bundling in this case was justified in lieu of separate ratings.

In considering routes to a higher rating, there was no limitation of motion which attains a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (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).  There was therefore no VASRD §4.71a route to a rating higher than 10% under any applicable code, and no grounds for additional rating based on the presence of instability.  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 pain condition.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71 the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification to 10% for each knee and did not elect to submit a minority opinion.  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 20160601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015450, 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 record of proceedings and majority recommendation (copy enclosed).  I reject the Board’s majority recommendation and accept the Board’s recommendation that your disability rating should be modified to 20% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  

	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