RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01433
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Cable Systems Installer-Maintainer, medically separated for “chronic bilateral knee and left ankle pain” with a disability rating of 10%.

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 - 20031211	VARD - 20040217	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee and Left Ankle Pain	5003	10%	Synovitis, Left Ankle with S/P Arthroscopic Debridement 	5271-5020	10%	20030428	
			Degenerative Joint Disease, Right Knee	5257	0%	20030428	
			Patellofemoral Pain Syndrome, Left Knee	5257	0%	20030428	
Mechanical Low Back Pain	Not Unfitting	Degenerative Joint Disease Lumbar Spine	5242	10%	20030428	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the bilateral knee pain and left ankle pain conditions under a single 10% disability rating, coded 5003.  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 or implied adjudication that each condition was separately unfitting.  IAW DoDI 6040.44 the panel must comply with the VASRD in addressing such combined adjudications by the PEB, and must therefore “unbundle” the component conditions; provided that each unbundled condition can be reasonably justified as separately unfitting in order to remain eligible for disability rating.  If the members judge that the conditions are separately unfitting as justified by performance based fitness criteria, separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  To that end, the evidence for the bilateral knee and left ankle conditions are presented separately; with attendant recommendations regarding fitness implications, and separate rating recommendations if indicated.

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition initially began when his right patella “slipped” during a physical training run in December 1992.  By 1996 he was being treated by physical therapy (PT) for bilateral knee pain, right greater than left.  After further PT evaluation and treatment in 1996, he was told nothing else could be done for his pain.  

The STR remained silent until 2003 when the CI felt his right knee give out during a duty demonstration for his specialty.  Knee X-rays on 31 January 2003 showed minor spurring at the anterior and superior aspects of the right patella; and a normal left knee.  At a 28 February 2003 orthopedic evaluation, 11 months before separation, the CI reported ongoing bilateral knee pain worsened by prolonged standing or running.  Physical examination showed bilateral range of motion (ROM) from 0 to 110 degrees (normal 0-140) with no weakness during flexion or extension.  There was bilateral pain with patellofemoral compression, but no marked crepitus. Both knees were stable with no joint line tenderness or effusion, and McMurray’s testing did not cause pain.  Knee X-rays were grossly normal except for elongation of the inferior pole/process of both patellae.  The 28 February 2003 permanent profile listed lower back pain, bilateral knee pain, and left ankle pain with restrictions on running, walking and lifting over 20 pounds.

At the 28 April 2003 VA Compensation and Pension (C&P) evaluation, 9 months before separation, the CI reported bilateral, aching knee pain related to the amount of walking each day.  He “pointed to his patellar tendons and below for his area of discomfort in his knees.”  Physical examination showed the knees were midline without valgus or varus deformity.  There was no pain on direct compression of both patella, and no laxity.  Bilateral knee flexion was 130 degrees with mild crepitus.  The CI could toe, heel and tandem walk without difficulty.  

At a 1 October 2003 PT appointment, left knee ROM was 0 to 130 degrees and right knee was 0 to 135 degrees.  At the 26 November 2003 MEB NASUM examination, 2 months prior to separation, the CI reported unchanging dull, aching bilateral knee pain, rated at 6/10, and increasing to 8/10 with walking or running.  He had to stop, rest, and slightly bend his knees for relief after activity, and had recently experienced his knees giving out while walking.  The examiner repeated physical findings from the 2003 C&P evaluation regarding stability, ROM and gait within normal limits.  The 2 December 2003 commander’s statement, 2 months prior to separation, referenced the above profile limitations and noted the CI’s medical conditions, including his knees, prevented him from climbing poles and doing aerial or underground cable installations required of his specialty.  Additionally, the commander noted that he could not perform other tasks due to pain. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right and left knees together as a bilateral knee condition, bundled with the left ankle pain condition at 10%, coded 5003 (degenerative arthritis), citing the VASRD rating criteria for degenerative arthritis for two or more major joints with X-ray evidence.  The VA rated the left and right knee conditions 0% each, coded 5257 (knee, other impairment of), citing no evidence of painful or limited motion of either knee.  The panel first considered if the right and left knee conditions met the threshold for separate rating, and determined the evidence was not clear that the either knee was associated with more disability than the other in this case.  While members agreed it was speculative to conclude that the disability was confined to a single knee and would have rendered the CI incapable of performing his duties, they also found it reasonable to surmise that it was the combined effect of both knees which rendered him unfit.  Furthermore, a bilateral diagnosis meets 5003 X-ray criteria for a single rating for “2 or more major joints;” and the panel agreed there were insufficient grounds for recommending a separate disability rating for each joint.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee conditions.  

Left Ankle Pain.  According to the STR and MEB NARSUM, the CI’s left ankle condition began in March 1996 during a basketball game when he felt a pop in the left Achilles tendon with immediate pain, swelling and tenderness.  He underwent Achilles tendon repair 2 days after the injury on 20 March 1996.  Following rehabilitation, he re-injured the left ankle during another basketball game on 27 February 2001 which caused marked bruising and pain.  After a year of therapy and treatment that included convalescent leave, a controlled ankle motion boot and PT, he was able to return to full duty status. 

On 8 October 2002, underwent a left ankle arthroscopy with debridement of scar tissue.  After an initial period of progress, his pain worsened and the left ankle was casted for 6 weeks.  After a second arthroscopy on 25 July 2003, the CI was noted to have a poor prognosis for rehabilitation and to meet military standards.  Radiographic studies on 5 March 2001 showed small joint effusion, soft tissue swelling surrounding the ankle joint and anterior medial consistent with acute sprain, pes planus, and slight irregularity of the talar dome cortex consistent with septal compression fracture.  A left ankle MRI on 20 November 2001 revealed increased fluid within the tendon sheath surrounding the flexor halluces longus consistent with tenosynovitis. 

At the 28 April 2003 C&P evaluation the CI reported continued dull left ankle pain around his medial malleolus, with occasional sharp shooting pain.  He could not run, jump or stand on a telephone pole for more than 30 minutes.  Physical examination showed the left ankle was larger than the right with an 11-cm scar along the medial side of the Achilles tendon.  Left ankle ROM (in degrees) was: dorsiflexion to 10 (normal 20), with shifting to the right during maneuvering; plantar flexion to 45 (normal), inversion to 20 and eversion to 10.  There was no laxity in the anterior and posterior dimensions.  

At the 25 July 2003 PT visit, 6 months prior to separation, the CI reported left ankle pain with intermittent Achilles tendon pain.  The CI had a non-antalgic gait and could toe walk without difficulty.  Physical examination revealed a left medial malleolus prominence of soft tissue swelling and tenderness of the Achilles tendon.  Left ankle ROM was dorsiflexion to 18 degrees and plantar flexion to 25 degrees.  Anterior drawer testing was negative with trace laxity noted.  

During the 26 November 2003 MEB NARSUM the CI reported constant, daily anterior/medial malleolus pain rated at 7/10, increasing to 9/10 with walking or activity.  He had been issued inserts but this increased lateral malleolus pain.  He continued home PT exercises without significant relief, but noted the ankle pain had remained stable since the last arthroscopy. The examiner repeated ROM measurements from the 2003 C&P evaluation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition bundled with the bilateral knee pain condition 10%, coded 5003 (degenerative arthritis), citing the VASRD rating criteria for degenerative arthritis of two or more joints supported by X-ray evidence.  The VA rated the left ankle condition 10%, coded 5271-5020 (limited motion of the ankle/synovitis), citing painful/limited motion.  The VA also rated the left ankle scar 0%, coded 7805 (scars, other).  Based on the evidence, the panel first agreed that the left ankle pain condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  When considering VASRD §4.71a criteria for a separated rating, members noted no limitation of dorsiflexion or plantar flexion which supported a rating under code 5271 for limitation of motion.  However, there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.40, §4.45 and §4.59).   The panel concurred that a 10% rating for functional loss (§4.40, §4.45) due to pain was supported by the evidence.  There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus), and no astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274).  The panel also considered whether the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7).  However, members agreed that the impairment did not more nearly approximate “moderately severe” to support a 20% rating under this code.  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 left ankle pain condition, coded 5099-5003.

Contended PEB Condition:  Low Back Pain (LBP).  According to the STR and MEB NARSUM, the CI’s low back pain condition began sometime following the Gulf War and was consistent with low back pain without radiculopathy.  The LBP increased following his knee and ankle injuries and he began PT.  Radiographic imaging on January 2003 showed no evidence of acute bony abnormality.  There was a mild lumbar spine tilt to the right and minor chronic changes involving the anterior and superior aspect of L5 with focal ostophytosis and a small Schmorl’s note involving the inferior L4 endplate.  Disc spaces were within normal limits.  At a 28 February 2003 orthopedic examination, 12 months prior to separation, the examiner’s only note about the CI’s back condition was that it was slightly limited in flexion at 75 degrees (normal 90).  

At the 28 April 2003 C&P evaluation CI reported backaches at the end of the work day and that his treatment included massage and electric stimulation in the past.  He had no morning stiffness, but experienced pain when bending forward after a day of work.  Physical examination revealed mild tenderness between L1 and L4, and no pain on compression of the sciatic joints.  Thoracolumbar flexion was to 85 degrees with lateral bending and rotation to 30 degrees.  Straight leg raise testing was negative to 90 degrees. He could toe-heel and tandem walk, and deep tendon reflexes were 2+ in the lower extremities, equal bilaterally.  The 26 November 2003 MEB NARSUM examination noted CI complaints of LBP, and repeated findings from the 2003 C&P evaluation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined that the low back pain condition was not unfitting and therefore did not rate it.  The VA rated the low back pain condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 9 months before separation, citing the VASRD spine rating criteria in effect at the time of the rating.  The panel’s main charge is to assess the fairness of the PEB’s determination that the low back pain was not unfitting.  The low back pain was profiled, and implicated in the commander’s statement and judged to fail retention standards.  There was performance-based evidence from the record that the low back pain condition significantly interfered with satisfactory duty performance at separation.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees).  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of the low back pain condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5099-5003 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left ankle condition, the panel unanimously recommends a disability rating of 10%, analogously coded 5099-5003 IAW VASRD §4.59.  In the matter of the contended low back pain condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 10%, analogously coded 5099-5003 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Ankle Pain	5099-5003	10%	
Low Back Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161014, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001597, 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