RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00429
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light-wheeled Vehicle Mechanic, medically separated for “bilateral knee pain” with a disability rating of 0%.

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 - 20031007	VARD - 20040511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Left Knee Disorder	5257-5003	10%	20040213	
			Right Knee Disorder	5257-5003	10%		
			Left Knee Laxity	5257	10%		
			Right Knee Laxity	5257	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee pain conditions under a single service disability rating, coded analogously to 5003 and rated them a combined 0%.  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.  The bilateral knees are presented together as they were examined and discussed together in the service treatment record (STR).  

According to the STR and the Medical Evaluation panel (MEB) narrative summary (NARSUM), the CI’s “bilateral knee pain” condition began in June 2001 without specific injury, with all pertinent entries referring to both knees.  Surgical intervention was not recommended by Orthopedics and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  At the 11 August 2003 orthopedic clinic appointment, the CI complained of constant bilateral knee pain with walking and running, and he could not perform PT or his MOS tasks.  On examination, the left and right knee ROM was flexion 135 degrees (normal 140) and extension 0 degrees (normal).  There was positive patellar grinding and examination tests for meniscus pathology were negative.  

During the September 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported constant painful and often swollen knees that locked and gave out.  He also reported using knee braces for comfort/stability.  Physical examination showed a CI wore neoprene knee sleeves, diffuse tenderness bilaterally with no effusion.  The 12 September 2003 MEB NARSUM examination, 3 months prior to separation, noted complaints of inability to perform aerobic exercise, sit or stand for prolonged periods of time and difficulty driving a vehicle.  Additionally, the CI had difficulty getting up, down and under vehicles as a mechanic and also had difficulty with lifting.  No physical examination was recorded.  At the 19 September 2003 orthopedic clinic appointment, 3 months prior to separation, the CI reported severe pain that increased with exercise and weight bearing.  On examination, there was a definite antalgic gait; and full ROM with pain on flexion and extension. The CI was unable to squat.  There was no crepitus and examination tests for meniscus pathology were negative.  

At the 13 February 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported constant dull and sharp pain, discomfort, popping, locking, rubbing and a grinding feeling within his knees.  Functional impairment includes standing, working, sports and activities of everyday living.  Physical examination showed normal gait and posture, with normal ROM.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “bilateral knee pain” condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing lack of x-ray changes or loss of motion.  The VA rated the “left knee disorder” and “right knee disorder” conditions 10% each, dual coded 5257-5003 (knee, other impairment of: slight - arthritis, degenerative); based on the C&P examination 2 months after separation, citing diagnosed degenerative arthritis based on X-ray evidence of narrowing of the medial compartment in both knees.  Additionally, the VA rated the “left knee laxity” and “right knee laxity” conditions 10% each, coded 5257 (knee, other impairment of: slight); based on the same C&P examination, citing slight subluxation in each knee.  The NARSUM and other STR evidence did not provide sufficient 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 impairment from either knee would not have unacceptably interfered with return to military training, members agreed that each knee was reasonably justified as separately unfitting.  

The panel considered the probative value of the examinations in evidence and adjudged that the 19 September 2003 General medicine clinic examination and VA evaluation had the highest probative value as being closest to separation, with both addressing goniometric measurements and pain on motion.  The panel next addressed ratings for each unfitting knee.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) in either knee.  However, there was evidence of pain with limited motion and functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee.  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). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends that each knee be unfitting with a disability rating of 10% for the left knee pain condition and 10% for the right knee pain condition, each coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the panel unanimously recommends a disability rating of 10% for each, coded 5099-5003 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	5099-5003	10%	
Right Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160711, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015293, 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