RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00319
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050325

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Chemical Operations Specialist, medically separated  for “chronic bilateral knee pain” with a disability rating of 0%.   

CI CONTENTION:  “Knee injury in Iraq.”  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 -20050211	VARD - 20050818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Chondromalacia Patella with Patellofemoral Pain, Left Knee	5257	0%	20050718	
			Status Post Excision, Right Tibial Tuberosity Claimed as a Rt Knee Condition	5257	NSC	20050718	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the bilateral knee pain conditions as a single unfitting condition coded analogously to 5003 (arthritis) and rated 0%.  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.  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 in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral knee condition is presented with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Right Knee Pain.  According to service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a known history of right knee pain due to Osgood-Schlatter’s disease prior to military service with surgical removal of a tibial tuberosity in December 1997.  The 17 November 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of ongoing pain, limitations on duty, and activities.  The CI could not run without significant worsening of his pain, walk or stand for prolonged periods, lift, or wear required military gear.  Physical examination showed right knee full range of motion (ROM) from 0 to 130 degrees.  Varus and valgus stress, anterior and posterior drawers test, Lachman’s and McMurray’s test were all negative for instability. 

At the 4 May 2005 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported no pain during the examination or for the previous several months.  Physical examination showed normal gait and shoe wear patterns.  There was no pain on motion, edema, effusion, instability, weakness, redness, heat, or guarding.  Additionally, there was no stiffness, giving way, locking, fatigability or lack of endurance noted.  Right knee ROM testing showed flexion at 140 degrees (normal) and extension at 0 degrees (normal).  The examiner documented “no symptoms for the past several months in the right knee, I find no condition or disability.”  

Left Knee Pain.  According to the STR and MEB NARSUM, the CI had no left knee issues until June 2003, when he took a physical fitness test while deployed, which required running in a sandy environment.  After the test, he experienced pain over the lateral aspect of his knee.  Two weeks later, the CI was evaluated for persistent pain and placed on anti-inflammatory medication.  Upon redeployment, the CI underwent a trial of physical therapy.  On 21 June 2004 and 13 September 2004, X-rays studies were normal.  

The 17 November 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of ongoing pain with duty and activity limitations.  Physical examination showed slightly decreased flexion to about 125 degrees and extension to 0 degrees.  Varus and valgus stress, anterior and posterior drawers test, and Lachman’s test were all negative.  McMurray’s testing caused some discomfort, but no audible clunk.  Tenderness was noted over the patellar tendon, lateral aspect of the joint-line, and medial plica.  Painful motion was not addressed.

The 4 May 2005 VA C&P evaluation noted a history (2000) of a direct blow to the left knee, initially thought to be a contusion or medial collateral ligament sprain.  The CI reported left knee pain rated at 4/10 but ranging from 3-8/10.  Pain was aggravated by prolonged sitting with bent knees, driving, repeated squatting, kneeling and climbing stairs.  There was a sensation of constant knee swelling, but no weakness, stiffness, heat, redness, instability, giving way, locking fatigability or lack of endurance noted.  Physical examination showed normal gait, no functional limitations, and normal shoe wear patterns.  ROM was flexion at 140 degrees (normal) and extension at 0 degrees (normal).  Medial and lateral collateral ligaments and anterior/posterior cruciate ligaments were intact with no motion. 

As previously elaborated, the panel must first consider whether each knee was separately unfitting, having been de-coupled from a combined PEB adjudication.  Members noted that the right knee was not profiled or specifically implicated in the commander’s statement and the NARSUM examiner noted full ROM, no painful motion, and stable ligaments.  The C&P examiner concluded that the CI had no right knee symptoms or disability, and members agreed that the evidence supports that the right knee was not unfitting.  The left knee was profiled and implicated in the commander’s statement and the panel thus agreed that the evidence supports that the left knee was separately unfitting. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing full motion and normal stability and imaging.  The VA rated the left knee condition 0%, coded 5257 (knee, other impairment of), based on the C&P examination, citing no instability, no pain on motion, and full range of motion.  The VA rated the right knee condition as not service connected, coded 5257, based on the C&P examination, citing no evidence that the condition was permanently worsened as a result of service.  There was no evidence of painful motion with functional loss 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).  No additional functional limitation was evidenced to support a rating higher than the 0% adjudicated by the PEB.  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 pain condition. 

BOARD FINDINGS:  In the matter of the 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 20170206, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180003519, 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.