RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00931
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050410

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

CI CONTENTION:  “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 - 20050217	VARD - 20050503	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Bilateral Patellofemoral Pain Syndrome	5024	0%	20050211	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 0% with likely application of the USAPDA pain policy 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 adjudicated by the PEB.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition began in June 2003 during his initial entry training.  No specific injury or trauma was noted.  X-ray studies performed on 24 October 2004 revealed areas of irregular calcification bilaterally and narrowed spacing behind the right kneecap.  Otherwise, both knees were unremarkable.  At the time of his 6 December 2004 physical therapy (PT) appointment, 4 months prior to separation, the examiner recorded knee range of motion (ROM) of 125 degrees flexion (normal 140) and normal extension in both knees.  Painful motion was present.  

The 15 December 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic daily bilateral knee pain that worsened with activity.  There were no complaints of locking or give way.  His physical examination (PE) revealed a normal gait.  Right knee ROM was flexion of 135 degrees with normal extension.  The left knee ROM was flexion of 125 degrees with normal extension.  Painful motion, effusion, or signs of instability were not present in either knee.  There was minimal joint line tenderness bilaterally.  

At the 11 February 2005 VA Compensation and Pension (C&P) evaluation, 2 months prior to separation, the CI reported constant bilateral knee pain that was aggravated by prolonged walking, standing, jumping, or running.  He denied incapacitation and there were no complaints of locking or give way.  His PE revealed full ROM of both knees that was not limited by pain, fatigue, weakness, lack of endurance, or incoordination.  There was tenderness to the surface of both kneecaps.  There was no evidence of swelling, redness, heat, crepitus, or joint effusion on either knee.  Tests for instability and meniscus problems were both negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions under a single service disability rating, analogously coded 5003 (degenerative arthritis) and rated 0% citing pain slight and intermittent.  The VA also combined the knee condition and rated 0% under code 5024 (tenosynovitis) citing normal examination findings.  

Panel members carefully reviewed the chronological STR during the 2-year pre-separation period and agreed that the CI’s overall condition, isolated treatments, and generally unchanging clinical symptoms did not significantly center about either knee independently, but rather a bilateral condition.  Panel members found it reasonable to surmise that it was the combination of pathology from both knees that rendered the CI unfit to perform his MOS duties.  Furthermore, the bilateral diagnosis does support the single 5003 based rating for “2 or more major joints;” thus there is VASRD §4.71a latitude for a bilateral rating in this case.  In regards to specific and alternative rating criteria, panel members also agreed that there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The most probative examination proximate to separation (VA) did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of a 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 their respective codes.  Additionally, there was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  

Panel member’s concluded that the PEB’s bundled rating of 0%, coded 5099-5003, was appropriate to both the pathology and disability in this case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB’s adjudication for the chronic bilateral knee condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, 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 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180004757, 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