RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01454
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20041221

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

CI CONTENTION:  “Unable to walk/stand for long periods of time.  Difficult to walk.”   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 (VA), 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 - 20041118	VARD - 20120216 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	0%	Patellofemoral Pain Syndrome with Strain, Right Knee 	5260	10%	20111210	
			Patellofemoral Pain Syndrome with Strain, Left Knee	5260	10%	20111210	
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 analogously to 5003 and rated 0% citing full range of motion without degenerative joint disease.  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 of the PEB.  The evidence for the right and left conditions are presented below with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee pain started during Advanced Individual Training in 2001 and gradually worsened over time.  The knee pain was aggravated by running, prolonged standing, sitting with knees flexed, or carrying heavy loads.  He denied any history of trauma.  He stated his right knee began giving him similar problems in February 2003.  An MRI on his left knee on 5 November 2003, 14 months before separation, showed a possible partial tear of the anterior cruciate ligament and there was a joint effusion.  No surgery was recommended.  The permanent profile listed bilateral knee pain.  The commander’s statement implicated the bilateral knee pain by noting the CI’s physical profile limited the performance of the duties of his MOS.  

The MEB NARSUM orthopedic addendum, dated 20 October 2004, 2 months prior to separation, noted complaint of bilateral knee pain, left worse than right.  Physical examination showed a normal gait.  There was tenderness bilaterally at the patellofemoral joints.  Bilateral knee range of motion (ROM) measurements were 0 degrees extension (normal 0) to 140 degrees flexion (normal 140).  There was no evidence of instability of either knee.  The leg below the knee was neurovascuarly intact with palpable pulses.  There were positive findings of patellar grind and quadriceps inhibition test (inhibition of the quadriceps muscles due to arthritis or traumatic injury on both knees).  Testing for meniscal pathology elicited pain (McMurray's maneuver); however, the pain was localized to the patellofemoral joint.  Left knee X-rays showed no evidence of arthritis.  The orthopedic specialist determined that the CI did not meet retention standards due to bilateral retropatellar knee pain.  

At the 10 December 2011 VA Compensation and Pension (C&P) evaluation, performed 7 years after separation, the CI reported intermittent knee pain.  He could not walk more than a quarter of a mile and could no longer run nor play sports.  He reported intermittent swelling and flare-ups 3 to 4 times per week and occasional use of a knee brace.  Physical examination showed right knee ROM of flexion 140 degrees (normal 140 degrees) and extension to 0 degrees (normal 0 degrees) and left knee flexion was 135 degrees and extension 0 degrees, with pain at end ROM flexion.  Knee ROM was not limited after repetitive motion.  Muscle strength, Lachman's test, drawer test, and valgus/varus stress test were normal.  There was no evidence of degenerative joint disease or patellar subluxation on X-rays.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded analogous to 5003 (degenerative arthitis), citing normal range of motion and radiographs.  The VA rated the left and right knee condition 10% each, coded 5260 (limitation of flexion of leg), citing painful motion based on the remote C&P examination.  The C&P examination, 7 years after separation, was too remote to have significant probative value for the panel’s rating recommendation of the disability due to the knees at the time of separation.  Therefore, the panel relied on the MEB examinations for its rating recommendations.  

The panel first considered if each of the right and left knee conditions having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The bilateral knees were permanently profiled; implicated by the commander’s statement; and, determined to fall below retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that each of the bundled right and left knee conditions was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting knee conditions at the time of separation.

There was no evidence of painful motion of either knee with functional loss 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 minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of 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 of either knee under the respective codes.  There was no fracture, non-union, 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).  The PEB assigned a 0% rating under 5003 for the bilateral knee condition and there was no evidence of arthritis of two or more major joints to support the next higher 10% rating for the bilateral knees.  No additional functional limitation was evidenced by the examinations.  Therefore, there was no higher rating available for either the right or left knee than 0% with any applicable VASRD code.  Having unbundled the bilateral knee condition, the panel arrived at 0% rating for each knee, with a combined rating of 0%, the same rating assigned by the PEB.  The panel found that separately rating the knees provided no ratings benefit to the CI and therefore no change to the PEB 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.  

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.  There were 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 20161012, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001605, 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