RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01344
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Automated Logistical Specialist, medically separated for “atypical chest pain” and “chronic bilateral knee pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  The CI made no specific contention.  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 - 20041007	VARD - 20121030	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Atypical Chest Pain	5099-5003	10%	No VA Placement	
Chronic Bilateral Knee Pain	5099-5003	0%	Left Knee Condition	5299-5257	NSC	20040723	
			Right Knee Condition	5299-5260			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Atypical Chest Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s atypical chest pain condition began in October 2003 while on medical hold for her bilateral knee condition (below).  At the initial evaluation on 10 December 2003, the pain was reproducible by palpation of the left breast.  During the 16 June 2004 MEB NARSUM examination, 5 months prior to separation, she had been evaluated in cardiology.  Testing included a stress test and echocardiogram.  She was thought to possibly have costochondritis, an inflammation of the cartilage junction between the ribs and sternum (breast bone).  The physical examination was unremarkable; reproduction of the pain was not recorded.  

At the VA Compensation and Pension (C&P) evaluation performed on 23 July 2004, 4 months prior to separation, the CI was not evaluated for chest pain.  The examination of the lungs, heart, breasts, and chest wall was unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the atypical chest pain condition 10%, coded analogously as 5003 (degenerative arthritis), citing pain, slight/constant.  The VA did not address the atypical chest pain condition.  The panel observed that the evaluation for the chest pain was essentially normal.  The physical examinations at both the NARSUM and C&P evaluations were unremarkable.  At the latter, the chest pain was not even listed for consideration.  The evidence available for review suggested that the condition had resolved by separation.  Regardless, no route to a higher rating was found.  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 atypical chest pain condition.  

Chronic Bilateral Knee Pain.  According to the STR and the MEB NARSUM, the CI’s left knee pain condition began in February 2002 prior to activation, apparently dated back to an injury 8 years earlier.  Shortly after activation, she presented for evaluation of the left and then also the right knee.  X-rays were unremarkable other than a bipartite left patella (kneecap), a developmental condition.  She was seen by a civilian orthopedist (records not in evidence) and given a knee immobilizer which she used for 3 months.  

At the 29 April 2004 orthopedic addendum for the MEB NARUM the CI reported daily pain aggravated by activity.  The range of motion (ROM) was limited to 130 degrees of flexion bilaterally (normal 140) with normal extension (0).  The knee was stable and otherwise unremarkable.  Painful motion was not recorded.  Repeat X-rays on 9 July 2004 were stable from the prior study.  

At the C&P evaluation the CI reported bilateral knee pain.  She had recently fallen and was using crutches which she had obtained on her own (not prescribed for use by a health care provider).  On examination, she was noted to be using crutches albeit improperly.  She had a brace on the left knee.  The ROM was identical to the NARSUM, 0-130 degrees bilaterally.  There was no further decrease with repetition.  She could partially squat.  Crepitus and tenderness were present on the left.  There was no comment on stability.  X-rays were normal.  The examiner noted that the evidence did not support a clinical diagnosis.  

The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the 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.  

Directing attention to its recommendations, the panel first considered if the bilateral knee pain condition met the panel’s threshold for a separate rating.  As noted above, the PEB bundled the bilateral knee condition and applied a single 0% rating coded analogously as 5003 (degenerative arthritis), citing normal X-rays, full ROM and strength, no laxity, and rated analogous to degenerative arthritis, without signs of degeneration.  The VA determined the bilateral knee condition was not service-connected.  The panel noted that there was no compensable limitation in motion, instability, indication of meniscal damage, or painful motion to support a compensable rating.  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 chronic bilateral knee pain condition.  

BOARD FINDINGS:  In the matter of the atypical chest pain and bilateral knee pain conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20160928, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180003420, 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