RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01526
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040304

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects the covered individual (CI) was a Reserve E6, Motor Transport Operator, medically separated for “chronic left knee and left ankle pain” with a disability rating of 10%.  

CI CONTENTION:  The CI contends the rating for his left knee and ankle conditions should be changed.  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 it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040115	VARD - 20041029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee and Left Ankle Pain	5099-5003	10%	Residuals Limited Flexion…Left Knee	5260	10%	20040721	
			Residuals, Limited Extension…Left Knee	5261	0%	20040721	
			Residual, Status Post Repair, Achilles Tendon, Left Ankle	5299-5271	10%	20040721	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Left Knee and Left Ankle Pain.  The PEB combined the left knee and ankle conditions as a single unfitting condition coded analogously to 5003 (arthritis) and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The approach by the PEB not uncommonly reflected its judgment 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, its recommendations may not produce a lower combined rating than that of the PEB.  The panel noted each condition was profiled, found medically unacceptable by the MEB, noted by the commander to restrict duty and had been surgically treated.  The panel agreed the evidence supported a recommendation that each condition was separately unfitting at separation.  The evidence regarding separate ratings for the left knee and ankle conditions is presented below.

Chronic Left Knee Pain.  According to the service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent surgical repair of his left Achilles tendon on 10 December 2002.  Post-surgical X-rays in January 2003 showed possible fluid collection above the kneecap (patella), but were otherwise normal.  The CI continued to complain of left knee pain and underwent a diagnostic arthroscopy on 13 May 2003 with microfracture of an osteochondral defect of the lateral femoral condyle and debridement of the medial meniscus for posterior horn tear.  

The 22 September 2003 orthopedic addendum to the MEB NARSUM for the knee, 5 months prior to separation, noted left knee pain which limited activity.  He was unable to walk over 1 mile without significant pain.  On examination, the gait favored the left side, but was nearly normal.  Range of motion (ROM) testing showed a slight limitation of flexion at 135 degrees (normal 140) and extension of 0 degrees (normal).  A test for meniscal irritation was positive for the medial meniscus.  Joint space narrowing, consistent with the surgery, was present on X-ray.  

At the 21 July 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported ongoing knee and ankle pain.  He worked for the Post Office as a letter carrier (vehicular) and denied loss of duty time due to his knee.  The physical examination showed limp was present on the left side without the use of an assistive device.  Flexion was 110 degrees extension lacked about 5 to 6 degrees from full.  Pain was noted with movement.  The knee was stable and signs of meniscal irritation absent.  Quadriceps atrophy of the knee was present.  The alteration in gait was attributed to the knee.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled left knee and the left ankle conditions 10% as a single condition, coded 5099-5003 (analogous to degenerative arthritis) citing the USAPDA pain policy.  The VA dual rated the left knee condition 10%,  coded 5260 (leg, limitation of flexion of) and 0%, coded 5261 (leg, limitation of extension of), based on the C&P examination citing limited flexion with pain and limited extension.  As noted above, the panel consensus was that the preponderance of evidence supported a recommendation that the left knee condition was separately unfitting.  The limitation in motion did not support a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The knee was stable and a rating under the code for instability (5257) was not supported.  However, the panel agreed the CI’s symptomatic left knee warranted a 10% rating under code 5259 (symptomatic removal of a meniscus).  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 knee condition, coded 5259.  

Left Ankle Pain.  As noted above, the CI had surgery of the left Achilles tendon in December 2002.  In podiatry on 13 August 2003, the CI had 10 degrees of dorsiflexion (toes up; normal 20) and 30 degrees of plantar flexion (toes down; normal 45).  On 3 September 2003, the ROM was 0 degrees dorsiflexion and 40 degrees plantar flexion.  The measurements for the unaffected right side were 10 and 45, respectively.  On 12 September 2003 in physical therapy, the CI was noted to walk without a limp.    

At the 11 November 2003 MEB NARSUM examination the CI reported daily pain which was aggravated by activity.  The physical examination showed tenderness and edema.  ROM testing showed dorsiflexion of 12 degrees on the right and 0 degrees on the left.  Plantar flexion was 38 degrees bilaterally.  Muscular strength was 5/5 for plantar flexion and inversion; however, it is was 4/5 for dorsiflexion and inversion.  
	
At the 12 July 2004 VA C&P evaluation the CI reported ongoing pain, but denied loss of duty time due to his ankle.  The physical examination showed a limp which was attributed to the knee.  No assistive device was in use.  Dorsiflexion was 3 to 5 degrees and plantar flexion was 25 degrees.  No calluses were noted on the feet.  Ankle measurements were equal in diameter.  

The panel directed attention to its rating recommendation based on the above evidence.  As already noted, the PEB rated the bundled left knee and the left ankle conditions 10% as a single condition, coded 5099-5003.  The VA rated the left ankle condition 10%, coded 5299-5271, (analogous to ankle, limited motion) citing moderate limited motion of the ankle, based on the C&P examination.  The panel considered if the limitation of motion was “moderate” or “marked” when considered under code 5271.  The limp was not seen at all examinations and was attributed to the knee at the C&P examination.  The CI was able to work as a letter carrier, albeit in a vehicle, without loss of work time.  In addition, the recorded ROM of the unaffected right ankle was also less than the VA normal values.  The panel agreed the ROM examinations proximate to separation were most consistent with the “moderate” level of limitation of motion required for the 10% rating under this code, and were supported by the presence of an abnormal gait and swelling.  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 condition, coded 5271.  

BOARD FINDINGS:  In the matter of the left knee condition, the panel unanimously recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  In the matter of the left ankle condition, the panel unanimously recommends a disability rating of 10%, coded 5271 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	
Chronic Left Knee Pain	5259	10%	
Chronic Left Ankle Pain	5271	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161016, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001821, 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 to 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 and to the counsel listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure