RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00732
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040816

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Duty E4, Accounting Specialist, medically separated for “bilateral knee pain” with a disability rating of 20%.  

CI CONTENTION:  “I had ACL surgery on left knee.”  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 - 20040506	VARD - 20051128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Degenerative Joint Disease of Knees	5003	20%	Residuals, Arthritis,…S/P Anterior Cruciate Ligament Meniscus Repair, Left Knee	5010	10%	20050927	
			Osteoochondritis Dissecans Versus Bone Bruise, Right Knee	5099-5010	0%	20050927	
	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Degenerative Joint Disease of Knee.  The PEB combined the left and right knee conditions as a single unfitting condition coded 5003 and rated 20%.  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 evidence for the right and left knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Knee Degenerative Joint Disease.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in January 1999 after the CI injured her left knee playing soccer resulting in a torn anterior cruciate ligament.  The CI underwent surgery in April 1999 for left anterior cruciate ligament reconstruction and a lateral meniscus debridement.  Despite surgery, the CI’s left knee pain worsened.  X-ray studies on 9 March 2004 showed moderate degenerative joint disease of the left knee.  

The 24 March 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of stiffness, numbness, and swelling in both knees.  Constant pain was reported that became severe by the end of the day.  Swelling was reported with walking.  Pain was increased with prolonged sitting.  CI reported inability to jump, rucksack or march.  Physical examination showed a slow, antalgic gait, left knee extension to 0 degrees (normal 0) and flexion to 95 degrees (normal 140) limited by pain.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the combined bilateral knee condition 20%, coded 5003 (arthritis, degenerative (hypertrophic or osteoarthritis).  The VA rated the left knee condition 10%, coded 5010 (Arthritis, due to trauma, substantiated by X-ray findings), based on the C&P examination 13 months after separation, citing painful or limited motion of a major joint.  

In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and the commander’s statement as preventing her from maintaining XVIII Airborne Corps Fit-to-Fight standards and both were profiled.  The panel concluded that the NARSUM provided satisfactory evidence for painful motion of both knees; thus, separate joint ratings are indicated IAW §4.71a.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the left 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).  

Right Knee Degenerative Joint Disease.  According the STR and the MEB NARSUM, the CI’s right knee condition began in March 2003 following a road march.  The CI was treated with temporary profiles and anti-inflammatory medications.  X-rays studies on 9 March 2004 showed mild degenerative joint disease of the right knee.  She was also found to have patellofemoral pain syndrome.  

The 24 March 2004 MEB NARSUM examination noted complaints of stiffness, numbness, and swelling in both knees.  Constant pain was reported to become severe by the end of the day.  Swelling was reported with walking.  Pain was increased with prolonged sitting.  The CI reported an inability to jump, rucksack or march.  Physical examination showed a slow, antalgic gait, right knee extension to 0 degrees and flexion to 125 degrees limited by pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the combined bilateral knee condition 20%, coded 5003 (arthritis, degenerative (hypertrophic or osteoarthritis).  The VA rated the right knee condition 0%, coded 5099-5010 (analogous to arthritis, due to trauma, substantiated by X-ray findings), based on the C&P examination 13 months after separation, citing no objective evidence of painful or limited motion.  See above for discussion of both knees being separately unfitting.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the right 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the combined bilateral knee condition.  

Contended PEB Condition:  Status-post Left Knee Anterior Cruciate Ligament Reconstruction.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  There was no evidence of continued laxity or joint instability associated with a deficient anterior cruciate ligament and any decrease in range of motion or painful motion was appropriately subsumed within the left knee degenerative joint disease.  Additional disability rating for any of the sequelae of the left anterior cruciate ligament reconstruction would violate the precepts of VASRD §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended status-post left knee anterior cruciate ligament reconstruction condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There were 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 20160910, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015822, XXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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