RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00528
BRANCH OF SERVICE:  army	SEPARATION DATE:  20061214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “chronic bilateral knee pain” with a disability rating of 10%.   

CI CONTENTION:  No specific contention made.  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 - 20060908	VARD - 20070529	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5003	10%	Chronic Bilateral Knee Pain	5010	10%	20070504	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5003 and rated 10% combined.  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 adjudicated by the PEB.  The evidence for the right and left knee conditions are presented together, with attendant separate unfitness recommendations, followed by separate ratings, if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began as early as 1999 with right knee popping.  Right patellofemoral pain syndrome was diagnosed in August 2004, and both knees became painful in March 2005 after a formation run.  On 27 June 2005, X-rays revealed minimal narrowing of the medial compartment of the patellofemoral and femorotibial joints, possibly “consistent with osteoarthritis and patellar tracking abnormality.”  At an orthopedic clinic visit in July 2005, the CI’s knees were tender but had full range of motion (ROM) and showed no swelling or effusion.  Treatment consisted of a nonsteroidal anti-inflammatory drug and physical therapy (PT).  At an orthopedic appointment in October 2005, the CI still had pain and crepitus in the knees, but no   swelling, instability or muscle weakness; surgery was not indicated.  In January 2006, the CI complained of anterior and retropatellar pain unresolved by inserts, profiles, PT, knee bracing or medication.  The examiner noted bilateral patellofemoral tenderness and crepitus. 

During the 6 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported arthritis since April 2005.  Physical examination showed right greater than left knee grinding, full ROM, and no significant instability or effusion.  The MEB NARSUM examination, performed the same day, noted complaints of bilateral knee pain.  Physical examination showed a normal gait, no gross deformities and full ROM with right greater than left retro-patellar crepitus.  There was bilateral patellofemoral tenderness but no evidence of ligamentous laxity (negative Lachman’s tests) or meniscal tears (negative McMurray’s tests).  Strength and sensation were both normal.  Measured ROM for the right knee was 3-115 degrees (normal 0-140), and the left knee was 3-120 degrees; painful motion was not observed.

On 23 March 2006, the commander’s statement consistently referred to the CI’s bilateral knee condition, and did not differentiate between the two knees regarding impact on duty performance.  The L3 physical profile, dated 20 April 2006, listed the medical condition that prevented performance of duties as “bilateral knee pain,” which reiterated an earlier temporary L3 profile from October 2005 which also listed both knees with no differentiation of left versus right.  On 31 August 2006, X-rays revealed no significant interval change in the “minimal early bilateral knee osteoarthritis.”  

At the 4 May 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported intermittent bilateral knee pain, with each knee equally impaired, and the use of knee braces when running.  Physical examination revealed a normal gait and no evidence of instability, heat, swelling, redness, ligamentous laxity, meniscal tears, crepitus or tenderness of either knee.  Bilateral ROM measurements were 0-140 degrees without pain, stiffness, weakness, incoordination or fatigability.  Knee X-rays revealed no fracture, dislocation or arthritic changes.

The panel first considered whether either or both knees met the panel’s threshold for separate ratings.  In this case, both knees were considered to fail retention standards, implicated by the NARSUM and the commander’s statement, and profiled.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to delineate the performance limitations attributable to either knee over the other.  Therefore, there was insufficient evidence to support the notion that either knee was separately unfitting since, other than the fact the right knee presented first, the symptoms, findings and treatments were essentially the same for both knees. 

The panel next directed attention to its rating recommendation based on the above evidence.  The FPEB rated chronic bilateral knee pain at 10%, coded 5003 (arthritis, degenerative), citing “two or more major joints with radiographic evidence of DJD (degenerative joint disease) and full range of motion.”  That adjudication supported an informal reconsideration of a PEB rating of 20% based on chronic bilateral knee pain with occasional exacerbations of incapacitating episodes of pain and X-ray evidence of osteoarthritis.  However, a memorandum for the PEB dated 11 July 2006 indicated the evidence did not support that the CI had “incapacitating episodes of pain.”  The VA rated chronic bilateral knee pain 10%, coded 5010 code (arthritis, due to trauma, substantiated by X-ray findings), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  Members noted there was no limitation of motion of either knee which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261), and there was no objective evidence of painful motion to separately rate either of the knees using that criteria. There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under that code for either knee.  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) for either knee.  However, coupled with the absence of limitation of motion, there was X-ray evidence of involvement of 2 or more major joints (i.e., each knee), which the PEB accurately rated at 10% using the 5003 VASRD code.  Therefore, there was no higher VASRD §4.71a rating than the 10% adjudicated by the PEB in the absence of “occasional exacerbations of incapacitating episodes of pain.”  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 chronic bilateral knee pain.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain and IAW VASRD §4.71a, the panel 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 20170216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007163, 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