RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01084
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041016

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

CI CONTENTION:  “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 - 20040806	VARD - 20051008	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Right Knee Patellofemoral Pain Syndrome	5260	10%	20040903	
			Left Knee Patellofemoral Pain Syndrome	5260	10%	20040903	
Neck Pain	Not Unfitting	Cervical Spine Degenerative Disc Disease and Rotational Subluxation of C1-C2	5242	10%	20040903	
Low Grade Left Ethmoid Adenocarcinoma	Not Unfitting	Left Ethmoidectomy, Sphenoidectomy, Frontal Sinusotomy with Middle and Superior Turbinate Resections for Low Grade Adenocarcinoma	6819	0%	20040903	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating 0%, coded 5099-5003 (analogous to degenerative arthritis).  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 Board 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 together, with attendant recommendations regarding separate unfitness and separate ratings, if applicable.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began after he completed jump school without specific injury.  His bilateral knee pain caused him to be reclassified after going through an MOS Medical Review Board (MMRB) from an Infantry MOS to an Intelligence MOS.  Distant radiographic studies in 1998 (MRI not in evidence) showed grade 3 chondromalacia of the bilateral knees.  Surgery was suggested.  However, the CI elected not to undergo corrective surgery, but rather opted for conservative treatment.  

The 30 January 2004 MEB NARSUM examination, 9 months prior to separation, noted persistent bilateral knee pain that interfered with the CI’s ability to run, jump, or march.  On examination the CI was noted to have bilateral patellar crepitus and bilateral patellar facet tenderness.  Provocative tests for meniscal pathology (patellar grind) were positive bilaterally.  There was no ligamentous laxity, no effusion, and no joint line tenderness bilaterally.  His range of motion (ROM) was 0 degrees of extension (normal 0) and 130 degrees of flexion (normal 140) bilaterally.  He had a normal gait, but had “difficulty with squats.”  The examiner also noted that X-rays of the bilateral knees “[demonstrated] no acute pathology.”  In regards to fitness, the examiner noted that the CI was unable to satisfactorily perform the duties required of his MOS because of “patellofemoral syndrome, bilateral, left greater than right.”  

During the 17 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported that his knees were painful when he did “a lot of standing or walking” and had “given out numerous times.”  Physical examination showed bilateral “retropatellar crepitus” and positive apprehension tests (provocative test indicative of patellar instability).  

On 14 July 2004, the commander stated that the CI had not been performing his required MOS duties because his “medical condition” caused him to be in a light duty/low stress environment.  Radiographic studies (X-rays) in August 2004 were normal showing no arthritis or structural abnormalities.  

At the 3 September 2004 Compensation and Pension (C&P) evaluation, performed 2 months before separation, the physical examination showed that the CI had a “slightly antalgic gait to his left side secondary to his knee problems as well as his foot problems.”  ROM measurements were 5 degrees of extension and 125 degrees of flexion, bilaterally.  Pain, stiffness, and crepitus were noted in both planes of movement.  The examiner noted that there was mild laxity on both knees, but provocative tests for knee instability were negative.  Provocative tests for meniscal tears were also negative.  The examiner estimated that the CI would have “very minimal physical impairment” from his bilateral knees, “even with acute flare-ups and repetitive motion.”  

The panel first considered if the bilateral knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel concluded there was not a preponderance of evidence in the STR which overcame the presumption that the bundled knee condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right and left knee conditions at the time of separation.  The PEB rated the bilateral knee conditions 0%, coded 5099-5003, with likely application of the US Army Disability Agency’s Pain Policy, citing “normal radiographs and full ROM.  Crepitus with motion.  Knee pain with running, prolonged standing or sitting [limited] performance in PMOS.”  The VA rated each knee condition 10%, coded 5260 (limitation of flexion), citing objective evidence of limited and painful motion of the knee joint.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261) for either knee.  The examinations proximate to separation did not demonstrate the presence of any significant 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 for either knee.  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) for either lower extremity.  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee condition, 5099-5003, and also a 10% rating for the left knee condition, 5099-5003.  

Contended PEB Condition:  Neck Pain and Low Grade Left Ethmoid Adenocarcinoma.  The panel’s main charge is to assess the fairness of the PEB’s determination that these conditions were not unfitting.  Although the neck condition was profiled, it was not implicated in the commander’s statement nor judged to fail retention standards.  The low grade left ethmoid adenocarcinoma was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  The NARSUM examiner indicated that the adenocarcinoma appeared “to be completely removed.”  There was no performance-based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee conditions, the panel unanimously recommends a disability rating of 10% for the right knee and 10% for the left knee, each coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended neck and adenocarcinoma conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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	
Right Knee Pain	5099-5003	10%	
Left Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160923, w/atchs
Exhibit B.  DD Form 294, dated 20161003, w/atchs
Exhibit C.  Service Treatment Record
Exhibit D.  Department of Veterans Affairs Treatment Record 

AR20170018120, 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