RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-01563
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040712

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

CI CONTENTION:  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 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 - 20040420	VARD - 20040805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Bilateral Knee Injury 	5257	0%	20040323	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY: 

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously 5099-5003 (degenerative arthritis) rated 0% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  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.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a long history of bilateral knee pain that began in June 1996 after trying to stop a moving/fleeing vehicle.  Right leg and right knee X-rays were negative. In January 1997 he was hit by a vehicle on the left side causing left knee pain.  He noted pain when running in December 1999 and again in September 2001.  Repeat right knee X-rays in November 2001 were negative.  He was treated for right knee pain with physical therapy in 2002.  In September 2003 he was treated with Motrin (a non-steroidal anti-inflammatory medication) for chronic knee pain assessed as retropatellar pain syndrome (RPPS).  On 25 September 2003 the CI reported a weight fell on his left knee 1 day earlier.  Examination revealed soft tissue swelling in the superior patellar area on the medial side.  There was tenderness in that area as well as on the medial side of the joint line and over the medial collateral ligament.  There was ligamentous stability; however, a full examination could not be done due to guarding.  X-rays of the left knee demonstrated no fracture or effusion.  The examiner’s assessment was medial collateral ligament strain secondary to blunt trauma.  An MRI performed on 3 November 2003 showed apparent edema and fluid in the left knee with possible strain or partial tear, but no ligament or meniscal tear was identified.  On 30 December 2003, the CI had tenderness to palpation over the left superior patella without any effusions.  There was no evidence of laxity or a meniscal tear.  The examiner assessed his condition as chondromalacia patella/RPPS and a possible partial tear of the medial head of the gastrocnemius muscle.

At the 21 January 2004 MEB NARSUM examination, 6 months prior to separation, the CI reported continued bilateral knee pain and swelling with running, jumping or being on his feet for extended periods of time.  He reported not taking any medications for the condition.  Physical examination noted “good” bilateral knee range of motion (ROM).  His right knee was stable and there was no effusion or grinding.  The left knee showed positive grinding and tenderness to palpation over the medial aspect of the knee and patella.  There was minimal effusion, no laxity (negative stability testing), and no evidence of a meniscal tear.  The commander’s statement dated 5 February 2004 indicated the CI was not physically capable of performing his military specialty functions or field duties.  A permanent L3 profile was issued on 9 March 2004 for chronic left knee pain with loss of cartilage.

At the 23 March 2004 Compensation and Pension (C&P) evaluation, 4 months before separation, the CI reported intermittent pain and swelling in both knees that occurred weekly and lasted for 6 hours.  Flare-ups caused interference with his ability to work, but did not cause incapacitation. Physical examination showed a normal gait and both knees were normal in appearance.  Physical examination recorded bilateral ROM of 0-140 degrees of extension to flexion (normal 0-140). There was no additional limitation of motion due to pain, fatigue, weakness, lack of endurance or in-coordination.  He had normal bilateral stability and meniscus testing.  X-rays of both knees were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee conditions together as bilateral knee pain 0%, coded analogously 5099-5003 (degenerative arthritis), citing the U.S. Army Physical Disability Agency pain policy. The VA also rated the left and right knee conditions together as a bilateral condition 0%, coded 5257 (knee, other impairment), based on the C&P examination 4 months before separation, citing a noncompensable evaluation without recurrent subluxation or lateral instability.  The panel concluded there was not a preponderance of evidence in the STR to overcome the presumption that the bundled knee condition was reasonably considered separately unfitting. The functional limitations of the bilateral condition contributed to the CI’s inability to perform his military duties.  Therefore, the panel considered its rating recommendation for each unfitting knee condition at the time of separation.

There was no evidence of painful motion with functional loss of either knee supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion 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 those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  The panel concluded there was not sufficient evidence to support a rating higher than the 0% for either knee.  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 chronic bilateral knee pain condition 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.  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 20161002, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004016, 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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure