RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-00339
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Air Defense Tactical Operations Center Enhanced Operator/Maintainer, medically separated for “arthritis degenerative joint disease both knees” with a disability rating of 10%.    

CI CONTENTION:  “Mental + physical degeneration!” 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 – 20080728	VARD - 20081209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis, Degenerative Joint Disease, Both Knees	5003	10%	Patellofemoral Syndrome, Left Knee	5257-5010	10%	20081121	
			Osteoarthritis Right Knee	5260-5003	10%	STR	
Situational Depression	Not Unfitting 	 No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Arthritis, Degenerative Joint Disease, Both Knees.  The PEB combined the right and left knee conditions under a single disability rating, coded 5003 and rated 10%.  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 bilateral knee conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had complaints of left knee pain that began in 1996 after jumping out of a helicopter, but he never sought medical attention.  Right knee pain began in 2003 with no mention of injury or trauma.  The CI stated he was able to continue his assigned duties.  After returning from a deployment in 2007 both knees were painful and he was unable to continue doing strenuous activities.  Orthopedic evaluation on 3 December 2007 revealed an anterior drawer sign demonstrated instability of the left knee.  Bilateral X-rays of the knees on the same day showed mild tri-compartmental osteoarthritis.  The CI underwent physical therapy (PT) which did not improve the pain.  A left knee MRI on 11 January 2008 showed moderate to severe patellofemoral joint cartilage loss, possible chronic posterior cruciate ligament injury, and degenerative fraying of the anterior horn lateral meniscus without evidence of displaced meniscal tear.  There was mild pre-patellar soft tissue edema.  

At the 27 May 2008 orthopedic clinic appointment, the CI was examined for complaints of chronic left knee pain.  The CI ambulated with some antalgia, favoring his left knee.  There was no effusion and the patella tracked normally.  Full range of motion (ROM) was reported.  The X-rays and MRI were reviewed, but the CI was not a surgical candidate as there were no symptoms of instability.

During the 19 June 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), months prior to separation, the CI reported “instability with lower extremities.” Physical examination showed crepitus (grinding) of the right and left knee, a posterior drawer sign (of a torn posterior cruciate ligament), and a positive sulcus sign (an indirect sign of a torn anterior cruciate ligament).

The 26 June 2008 MEB NARSUM examination, 3 months prior to separation, noted complaints of daily pain and stiffness whenever he had to do activities requiring him to bend his knees such as climbing stairs, lifting, or sitting for long periods.  Physical examination showed normal strength, no swelling, muscle atrophy, or sensory deficits, and the extremities were neurovascularly intact.  The left knee ROM following repetitive movement was flexion of 135 degrees (normal 140) and extension of -10 degrees (normal 0).  The right knee ROM following repetitive movement was flexion of 135 degrees and extension of -10 degrees.  Objective evidence of painful motion was not reported and gait was not addressed.  There was no laxity, instability, muscle atrophy, patellar ligament or patella pain, or evidence of a meniscal tear.  

At the 21 November 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported stiffness and achy knees upon awakening that improved once he started moving around.  Sitting, lifting, climbing stairs, or bending his knees caused persistent aching in both knees, so he learned to avoid these activities.  Overall he rated the pain in both knees an intermittent 7/10 with rare locking and giving way.  The CI denied missing any work in the past year.  Physical examination noted overall stable knees.  Strength, sensation, and deep tendon reflexes were all intact and there was no muscle atrophy.  On examination, the left knee ROM following repetitive movement was flexion of 135 degrees and extension of -10 degrees as was the right knee.  Overall the knees were stable with no instability or evidence of a meniscal tear.  Following repetition there was no additional limitation in ROM or joint function due to pain, fatigue, weakness, lack of endurance, or incoordination.  Objective evidence of painful motion was not reported and gait was not addressed.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left knee with the right knee condition and applied a single 10% rating, coded 5003.  The VA rated the left knee condition 10%, coded 5257-5010 (knee, other impairment-arthritis, due to trauma, substantiated by X-ray findings), based on the C&P examination, citing painful or limited motion of a major joint of group of joints and may also be applied once to multiple joints if there is no limited or painful motion.  The VA rated the right knee condition 10%, coded 5260-5003 (leg, limitation of flexion-arthritis, degenerative), based on the C&P examination, citing the same rationale as the left knee.    

In this case, both knees were considered to fail retention standards, both were implicated by the NARSUM and the commander’s statement and both were profiled.  The panel concluded there was not a preponderance of evidence in the service records which overcame the presumption that the bundled knee condition was reasonably considered separately unfitting.  There was no satisfactory objective evidence of painful motion or compensable limitation of motion, so a bilateral 10% rating under the provisions of 5003 as adjudicated by the PEB was considered by the panel.  X-ray evidence specified bilateral osteoarthritis.  Therefore, the combining of two or more major joints, was permissible under the VASRD 5003 rating requirements, and this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  

Both the NARSUM and VA examinations recorded knee extension of -10 degrees following repetitive motion; this raised consideration of code 5263 (genu recurvatum, acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) for each knee.  However, despite hyperextension being present in both knees on separate examinations, no diagnosis of genu recurvatum was made.  Furthermore, the panel discussed the question of whether genu recurvatum is in scope or not, and presumably it is not in accordance with PDBR guidelines since the PEB unfitting diagnosis was arthritis degenerative joint disease, both knees.  There was no evidence to support the use of code 5263 in the absence of weakness and insecurity in weight-bearing objectively demonstrated for either knee.  After due deliberation, and considering all the evidence, the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee arthritis degenerative joint disease.

Contended PEB Condition:  Situational Depression and Anxiety.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander's statement and did not fail retention standards. There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended situational depression and anxiety condition, the panel recommends no change from the PEB determination as not unfitting.  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 20170207, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180013232, 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.