RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00825
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Wheeled Vehicle Repairer, medically separated for “chronic bilateral knee pain” with a disability rating of 0%.

CI CONTENTION:  Current condition supports a higher rating.  Additional unfitting conditions were not considered.  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 – 20040723	VARD - 20040925	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	0%	Chondromalacia, Left Knee	5260	10%	20040823	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Bilateral Knees.  The PEB combined the right and left knee conditions under a single disability rating, analogously coded 5099-5003 and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy AR 635-40 B24.f.  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, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s knee condition began in March 2003 while running.  Radiographic imaging (X-rays, bone scan and MRI) were all normal.  Orthopedics diagnosed retropatellar pain syndrome in September 2003.  The 9 July 2004 MEB NARSUM examination, 1 month prior to separation, noted complaints of bilateral knee pain (left greater than right), exacerbated by prolonged standing, squatting, bending, and stooping.  Physical examination showed a positive patellofemoral grind (abnormal patellar movement and painful crepitation) bilaterally (left greater than right), with no effusion (fluid collection) or ecchymosis (bruising).  Instability and meniscus testing were negative.  Bilateral knee range of motion (ROM) was flexion to 110 (140 normal) and extension to 0 degrees (normal 0); painful motion was not addressed.

At the 23 August 2004 VA Compensation and Pension (C&P) examination, 4 days before separation, the CI reported bilateral knee pain and occasional swelling.  Physical examination documented a normal gait.  Bilateral recurrent subluxation (incomplete dislocation), locking pain, or joint effusion were absent.  There was left knee crepitus.  Right knee ROM was flexion of 140 (140) and extension of 0 (0) degrees.  Left knee ROM was flexion to 135 and extension to 0 degrees.  There was no additional limitation based on pain, fatigue, weakness, lack of endurance, or incoordination.

The panel directed attention to its rating recommendation based on the above evidence.  The panel concluded there was not a preponderance of evidence in the STR to overcome the presumption that the bundled knee condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting left and right knee conditions at the time of separation.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing pain rated as slight and intermittent under the USAPDA pain policy.  The VA rated the left knee condition 10%, coded 5260 (leg, limitation of flexion), based on the C&P examination 4 days before separation, citing pain on motion as evidenced by the left knee crepitus found in the STR.  There was no VA record in evidence for the right knee.

The panel agreed there was no limitation of flexion or extension for either knee that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 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 these 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 insufficient evidence of painful motion with functional loss to support a 10% rating for each knee (based on §4.59, §4.40 and §4.45) as evidence by the VA examination most proximate to separation.  Additionally, a bilateral 10% rating under the provisions of 5003 was considered.  The panel determined that the MEB NARSUM and C&P examinations did not provide satisfactory evidence for bilateral painful motion; thus, separate joint ratings are not recommended.  The panel concluded that the combined rating of 10% for two major joints, coded 5099-5003, is a good analogy to the CI’s bilateral retropatellar pain syndrome pathology and disability.  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 bilateral knee condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were 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	
Bilateral Knee Pain, due to Retropatellar Pain Syndrome	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 13 September 2016, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170018009, 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