RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00685
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Administrative Specialist, medically separated for “chronic bilateral knee pain” with a disability rating of 10%.

CI CONTENTION:  No specific contention was 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 - 20060124	VARD - 20061229	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Bilateral Knee Disability	5299-5257	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Right Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent right knee diagnostic arthroscopy on 6 February 2004 which found chondromalacia of the patella and the lateral tibial plateau as well as a right knee medial plica.  The medial and lateral menisci were noted to be intact under direct visualization.  A 16 November 2005 X-ray revealed no bone, joint or soft tissue abnormality.  At the orthopedic clinic appointment on 23 June 2005, 8 months prior to separation, the physical examination revealed full ROM, a positive patellar grind test and patella crepitus.

The 15 November 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of continued knee pain that was aggravated by standing or sitting for long periods.  Physical examination showed no edema, atrophy or discoloration.  ROM performed by physical therapy was flexion of 110 degrees (normal 140) and extension (hyperextension) of -10 degrees (normal 0); painful motion was present.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing application of the USAPDA pain policy.  The VA did not service connect the bilateral knee condition, analogously coded 5299-5257, (knee, other impairment), based on the STR from a previous period of active duty, citing no evidence of a current diagnosis to support a disability.

The panel first considered if the right knee condition met the panel’s threshold for a separate rating as elaborated above.  The panel concluded there was not a preponderance of evidence in the STR which overcame the presumption that the left and right knee conditions were reasonably considered separately unfitting.  

The panel then considered its rating recommendation for the unfitting right knee condition at the time of separation.  There was no limitation of flexion or extension that supported a rating under codes 5260 or 5261.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history to remove a portion of a meniscus (5259).  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 (based on §4.59, §4.40 and §4.45), as recorded on the MEB physical therapy examination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a separate disability rating of 10% for the right knee condition, coded 5099-5003.

Left Knee Pain.  According to the STR and the MEB NARSUM, the CI underwent left knee diagnostic arthroscopy on 28 June 2004 with a finding of severe chondromalacia of the patella.  Post-surgical X-rays revealed left knee degenerative changes.  At the orthopedic clinic appointment on 23 June 2005, 8 months prior to separation, physical examination revealed full ROM, a positive patellar grind test and patella crepitus.

The 15 November 2005 MEB NARSUM examination, 3 months prior to separation, showed no edema, atrophy or discoloration.  ROM performed by physical therapy was flexion of 50 degrees and extension to -5 degrees (hyperextension); painful motion was present.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10% and the VA did not service connect the bilateral knee condition as noted above.  In addition, the panel agreed the left knee condition met the panel’s threshold for a separate rating as elaborated above.  

The panel then considered its rating recommendation for the unfitting left knee condition at the time of separation.  There was no limitation of flexion or extension that supported a rating under codes 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 removal of a portion of a meniscus (5259) to justify rating under the respective 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 (based on §4.59, §4.40 and §4.45), as reported on the MEB physical therapy examination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a separate disability rating of 10% for the left knee condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends separate disability ratings of 10% for the right knee condition and 10% for the left knee condition, both coded 5099-5003 IAW VASRD §4.71a.  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 as of the date of the prior medical separation:

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

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 Treatment 

AR20180004735, 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