RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00552
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20050629

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

CI CONTENTION:  “Please review all conditions.”  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 - 20050421	VARD - 20051222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Patellar Femoral Syn. Left Knee	5260	0%	20051004	
			Patellar Femoral Syn. Right Knee	5260	0%	20051004	
Recurrent Back Pain	Not Unfitting	Residuals, Recurrent Back Pain	5237	0%	20051004	
Pes Planus	Not Unfitting	Bilateral Pes Planus	5276	NSC	20051004	
Left Wrist Pain	Not Unfitting	Left Wrist	5019-7819	0%	20051004	
Depressive Disorder	Not Unfitting	Depressive Disorder	9434	10%	20050929	
Vision Defect	Not Unfitting	No VA Examination in Evidence	
Uterine Fibroids	Not Unfitting	Uterine Fibroids	7613	NSC	20051006	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 (arthritis, degenerative) and rated 0% with application of the US Army Physical Disability Agency (USAPDA) 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 and MEB narrative summary (NARSUM), the CI had knee problems since basic training.  She was first seen for bilateral knee pain on 16 May 2003.  She continued to complain of pain despite the use of anti-inflammatories and neoprene knee sleeves.  She was referred to physical therapy (PT) with some improvement noted.  In November 2003 she received steroid injections and additional PT.  Pain continued and a bone scan in August 2004 revealed uptake in the right mid-tibia suggestive of a stress fracture and was otherwise unremarkable.  Bilateral knee X-rays in October 2004 were normal.  

At the 14 March 2005 orthopedic MEB consult, 4 months prior to separation, the CI reported complaints of pain in the anterior knees with occasional swelling.  Standing more than 15-30 minutes also caused discomfort as she was a cook which required being on her feet.  On examination, heel and toe gait were normal.  There was full range of motion (ROM) of the knees with excellent patellar tracking, no crepitus, and no palpable discomfort to the knees.  X-rays of the knees were reported as normal.  Painful motion was not reported.  

The 5 April 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic knee pain with any type of weight-bearing or impact activities, sitting with her knees flexed, running, squatting, kneeling, or crawling.  The examiner referred to the 12 March 2005 orthopedic MEB consult (above) for the physical examination of the knees as well as a 17 December 2004 civilian rheumatologist evaluation which reported stable collateral ligaments and a slight fluid wave in both knees with a full ROM and minimal pain on motion.  

At the 4 October 2005 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported pain, stiffness, and swelling of the bilateral knees.  Physical examination showed knee flexion to 140 degrees (normal 140) and 0 degrees extension (normal 0) bilaterally.  ROM was reduced to 120 degrees after repetitive movements bilaterally, with left knee crepitus.  Under additional limitations of joint function for pain or lack of endurance, the examiner reported additional limitation of 20 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right knee with the left knee and applied a single 0% rating (coded analogously to 5003) with application of the USAPDA pain policy.  The VA rated each knee condition 0%, coded 5260 (leg, limitation of flexion), based on the C&P examination, citing “no medical evidence showing arthritis of the knee with some limitation of motion or limitation of motion that is compensable” and consideration of DeLuca.  

Both knees failed retention standards, were profiled, and implicated in the commander’s statement.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled knee condition was reasonably considered separately unfitting.  

The panel then considered its rating recommendation for the unfitting right and left knees at the time of separation.  Each knee was clinically similar with the same findings and rating for each knee is identical.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating for each knee (based on §4.59, §4.40 and §4.45) as documented in the rheumatologist’s evaluation and source C&P examination.  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5099-5003.  

Contended PEB Conditions:  Back Pain, Left Wrist Pain, Depressive Disorder NOS, Pes Planus, Vision Defect, and Uterine Fibroids.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Only the vision defect was profiled (E2).  None of the contended conditions were judged to fail retention standards.  The MEB psychiatric NARSUM determined the mental health condition was fitting for military duty and not a boardable condition.  The commander commented on the CI’s inability to stand for long periods of times or lift heavy equipment required for her job as a cook due to her knees.  The commander stated the CI was able to operate in an administrative capacity only.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions.so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended back pain, left wrist pain, depressive disorder, pes planus, vision defect, and uterine fibroids conditions, the panel recommends no change from the PEB determinations as not unfitting.  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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Knee Pain Syndrome	5099-5003	10%	
Left Knee Pain Syndrome	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170112, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180004704, 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 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.

Sincerely,					      
						      					
Enclosure