RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01389
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Fire Support Specialist, 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 - 20040823	VARD - 20050406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain, Patellofemoral Pain Syndrome (PFPS)	5099-5003	0%	Left PFPS	5260	10%	20041222	
			Right PFPS	5260	10%	20041222	
Seasonal Allergic Rhinoconjunctivitis	Not Unfitting 	No VA Placement	
Gingivitis			
Dyspepsia			
Atypical Chest Pain			
Low Back Pain		Lumbar Strain	5237	0%	20041222	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  This 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 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 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 adjudicated by the PEB.  The evidence for the right and left knee conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain began in November 2002 several weeks into basic training, with no specific injury identified.  The CI was diagnosed with bilateral patellofemoral pain (runner’s knee).  At the 29 December 2003 orthopedic examination, 9 months prior to separation, the CI complained of persistent right knee pain.  Physical examination showed right knee tenderness and range of motion (ROM) was extension to flexion of -5 degrees-140 degrees (normal 0-140); painful motion was not addressed.  The ligaments of the right knee were stable, but testing for possible right knee cartilage damage testing was positive for pain. The orthopedic surgeon discussed possible diagnostic arthroscopy of the right knee but the CI declined and noted that without the rigors of military life, he believed his knee would “not bother him significantly.”

During the 22 July 2004 MEB examination (recorded on the DD Forms 2807-1 and 2808), 2 months prior to separation, the physical examination showed crepitus (a crackling or grinding noise or sensation) and facet pain (pain at particular points or areas on the knee cap, or patella).  Knee ROM was extension to flexion of 0-130 degrees; painful motion was not addressed.  There was no evidence of effusion or instability.  At the 22 July 2004 MEB NARSUM examination, 2 months before separation, the CI reported constant bilateral knee pain for which he had ceased taking anti-inflammatory medications.  Physical examination cited the findings of the aforementioned MEB DD Form 2808 examination.

The 27 July 2004 permanent L3 profile specified bilateral patellofemoral pain as the underlying condition.  The 11 August 2004 commander’s statement did not specify one knee as more limiting than the other, instead addressing “conditions” as preventing functional activities.  The commander documented the CI’s physical limitations as the inability to:  run, march, walk, and move with a fighting load; which impaired the CI’s ability to successfully perform his military specialty duties and functional soldier activities.

At the 22 December 2004 VA Compensation and Pension evaluation, 3 months after separation, the CI reported constant bilateral knee pain which was not being treated.  The CI was working as an automobile mechanic which caused pain when kneeling to change tires, but had no effect on daily activities.  Physical examination showed a normal gait.  The examiner specifically noted an absence of pain on motion and recorded bilateral knee ROM of extension to flexion of 0-134 degrees with no change on repetition of motion.  Bilateral testing for ligamentous instability and meniscal (cartilage) damage was negative.  Bilateral knee radiographic imaging was normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing the USAPDA pain policy rated as minimal and constant.  The VA rated the left and right knee conditions each at 10%, coded 5260 (leg, limitation of flexion).  The panel first considered whether the individual left and right knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. The knees were profiled together and were not given individual attribution by the commander’s statement as limiting duties; rather, each knee equally impaired the CI’s successful performance of his duties.  The MEB NARSUM documented the CI’s chief complaint as bilateral knee pain and opined that the bilateral knee condition fell below retention standards.  The commander’s statement, profile, and other STR evidence provided no information which would permit the panel to discriminate performance limitations attributable to either knee from the other.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled knee condition were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right and left knee conditions at the time of separation.

There was no evidence of painful motion of either knee supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion of either knee which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no history or evidence 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 that those codes for either knee.  There was no fracture, nonunion or malunion of the right or left femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation of either knee was evidenced by the examinations.  Although the panel recommends that each knee condition was separately unfitting at separation, a rating greater than 0% is not supported for either knee with any applicable VASRD code.  Therefore the panel concluded there was insufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  The panel also noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating and therefore no change to the PEB’s combined adjudication is recommended.  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 bilateral knee condition.

Contended PEB Conditions:  Seasonal Allergic Rhinoconjunctivitis, Gingivitis, Dyspepsia, Atypical Chest Pain, and Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended seasonal allergic rhinoconjunctivitis, gingivitis, dyspepsia, atypical chest pain, and low back pain conditions, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel 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 20160705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001575, 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