RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01335
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Network Switching Systems Operator, medically separated for “bilateral knee and left ankle pain,” with disability rating of 10% 

CI CONTENTION:  The CI makes no specific contentions.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040211	VARD - 20040723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee and Left Ankle Pain	5099-5003	10%	S/p Left Ankle Cyst Removal with Residual Pain...	5000-5003	10%	20040318	
			Right Knee Osteoarthropathy	5099-5003	10%	20040318	
			Left Knee Osteoarthropathy	5099-5003	10%	20040318	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Bilateral Knee and Left Ankle Pain.  The PEB combined the bilateral knee and left ankle conditions as a single unfitting condition coded analogously to 5099-5003 (analogous to arthritis, degenerative) 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’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 bilateral knee and ankle condition are presented with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right knee condition began in September 2001, after his right knee was inadvertently struck with a pugel stick.  No medical care was sought at that time.  In October 2001, during a 15-mile road march, the CI stepped into a hole and twisted his left ankle.  The CI was diagnosed with a grade III left ankle sprain.  He was treated with casting, crutch ambulation and 30 days convalescent leave.  In November 2001, during physical training, the CI developed severe pain and swelling in his right knee and left ankle.  The pain did not resolve with activity modification and anti-inflammatory medication.  In 2001 bone scan studies showed a left ankle bone contusion.  In June 2002 the CI underwent an arthroscopy and excision of a ganglion of the left ankle.  The CI continued to have daily pain in his right knee and left ankle.  On 3 February 2003, magnetic resonance imaging (MRI) of the right knee was normal. A 2 December 2003 X-ray of the left ankle and bilateral knees were normal.  A 17 December 2003 MRI of the right knee showed no evidence of significant internal derangement of the right knee and no changes noted from prior examinations in February 2003.

The 2 December 2003 MEB NARSUM examination, 5 months prior to separation, noted the CI wore a sleeve brace on his right knee.  The CI wore an air cast on the left ankle and reported that he could walk short distances, but relied on pain medication and anti-inflammatories for mild pain relief.  Physical examination showed no gross edema or an antalgic gait.  Right knee pain was noted with all motion.  No examination of the left knee noted. The left ankle examination showed pain to palpation anteriorly and laterally, but there was pain and stiffness with dorsiflexion and plantar flexion. The ankle was stable, but very painful and stiff with eversion and inversion.  There was no edema or swelling of the right knee or left ankle.

At the 4 December 2003 physical therapy examination range of motion of showed bilateral knee flexion to 130 degrees (normal 140) and normal extension (0 degrees).  The right ankle demonstrated dorsiflexion to 10 degrees and normal plantar flexion (45 degrees).  

At the 18 March 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported symptoms pain, stiffness and weakness of the left ankle.  The CI reported bilateral knee pain with decreased mobility.  He reported the use of Percocet and Motrin for pain.  Physical examination showed abnormal gait.  Bilateral knee range of motion was normal with painful motion of the right knee.  Physical examination showed left ankle range of motion of dorsiflexion 5 degrees and plantar flexion 30 degrees.  Range of motion was limited by pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee and left ankle pain condition 10%, coded 5099-5003 (analogous to arthritis, degenerative), citing range of motion is within normal limits and rated for pain as moderate and frequent with likely application of the US Army Physical Disability Agency pain policy.  The VA rated the right knee, left knee, and left ankle separately at 10% each, coded 5099-5003 (analogous to arthritis, degenerative) based on the C&P examination 2 months before separation, citing the right knee had painful and limited flexion, the left knee revealed no painful or limited motion but did show crepitus and degenerative arthritic changes, and the left ankle had painful and limited motion. 

The panel first considered each condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees and ankles were implicated in the commander’s statement; however, treatment records evidenced multiple visits for right knee and left ankle pain.  Panel member agreed that the evidence reasonable supports that the right knee and left ankle were separately unfitting and accordingly separate disability ratings are recommended.  Panel members agreed that the preponderance of the evidence supports that the left knee could not be reasonably justified as separately unfitting and accordingly a separate disability rating is not recommended.  

The panel next considered it rating recommendations for the right knee and left ankle.  There was no compensable limitation of motion of the right knee; however, there was evidence supporting a 10% rating for painful motion.  The left ankle demonstrated moderate dorsiflexion limitation of motion for a 10% rating under VASRD code 5172.  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 right knee condition coded 5271 and 10% for the left ankle pain condition coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends the right knee as unfitting and a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  In the matter of the left ankle condition, the panel unanimously recommends the left ankle as unfitting and  a disability rating of 10%, coded 5009-5003 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	
Right Knee Pain	5271	10%	
Left Ankle Pain	5099-5003	10%	
COMBINED 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161001, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180002712, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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