RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01044
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20050831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National guard E4, Information Systems Operator/Helicopter Repairer, medically separated for “chronic pain, bilateral knees” and “chronic pain, left ankle,” with a disability rating of 0%.  

CI CONTENTION:  “I believe my condition was more severe than the evaluation and should have received at least 10% for my ankle.  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 - 20050810	VARD - 20061130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Bilateral Knees And Left Ankle	5099-5003	0%	Patellofemoral Syndrome, Right Knee with Osteoarthritis	5010-5260	10%	20060801	
			Patellofemoral Syndrome, Left Knee with Osteoarthritis	5010-5261	10%	20060801	
			Left Ankle Strain	5271	0%	20060801	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pain, Bilateral Knees and Left Ankle.  The PEB combined the left and right knee pain and the left ankle pain conditions under a single disability rating, coded 5003 (arthritis, degenerative) and rated 0% with application of the US Army Physical Disability Agency 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.  The evidence for the left knee, right knee and left ankle conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Bilateral Knee Pain.  According to the service treatment record (STR) and the MEB narrative summary, the bilateral knee pain condition began in 1993 while on active duty.  He was later diagnosed with patellar femoral syndrome (PFS) on 7 December 2004.  Duty limitations were recommended by the Army on 28 July 2005 which included no running, walking, biking, or swimming.  Additional limitations included the inability to carry a rucksack, wear a Kevlar helmet or conduct any impact exercises.  

During a 29 January 2004 Primary Care Clinic (PCC) appointment, the CI complained of bilateral knee pain.  He stated the pain was worse with running and walking up and down stairs.  Examination showed pain was present around the patella.  The CI completed a full range of active motion with strength of 5/5.  Medication for the pain was prescribed.  At the 6 February 2004 acute care follow-up appointment, the CI stated the bilateral knee pain felt much better with medication and requested a temporary profile for running.  He was scheduled for a physical fitness test in 4 weeks.  Examination revealed patella tendonitis.  During the 9 January 2005 orthopedics clinic examination, the CI was diagnosed with bilateral PFS or patellar tendonitis.  At the 11 January 2005 PCC appointment, the CI complained of bilateral knee pain.  Pain intensity was less while resting and worse during activity.  The left knee pain was worse than the right knee.  The examiner noted bilateral knee pain with no deformity, edema or grinding of the knee.  On 21 January 2005 magnetic resonance imagining (MRI) studies of the right knee showed mild quadriceps tendinopathy.  MRI studies of the left knee on 5 March 2005 showed a very small joint effusion.  

The 17 June 2005 MEB NARSUM examination, 2 months prior to separation, the CI complained of bilateral knee pain.  Pain increased with physical activity and would intermittently go to 9/10, with 10 being the worse.  There were no complaints of locking or giving way.  Physical examination of the left knee range of motion (ROM) was flexion of 92 degrees (normal 140).  Physical examination of the right knee ROM was flexion of 87 degrees.  There was mild crepitus with active ROM of both knees.  The right knee was tender.  The inferior/anterior patella area and inferior patella poll of the left knee were also tender.  A goniometer was used for measurements and no pain with motion was noted.  

At the 1 August 2006 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported a gradual onset of left and right knee pain which began in 1994.  He reported pain every day with swelling, locking, popping and grinding sensations.  He stated that he did wear a brace, but did not use a cane or crutch.  He took 800 mg ibuprofen without relief and was unable to sit more than 30 minutes, unable to kneel, unable to run, unable to stand for more than two hours, and unable to walk for more than four hours.  

Physical examination of the left knee showed the CI walked without a limp, using no assistive device.  Bilateral knees revealed 5/5 motor strength and 2+ deep tendon reflexes.  On examination, the bilateral knee range of motion (ROM) following repetitive movement was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal 0) without painful motion.  There was no crepitus, erythema, warmth or tenderness.  The CI had some tendon popping on the left knee.  There was no instability or additional limitations by pain, weakness, or lack of endurance following repetitive use.  X-ray studies showed normal knees.  Examination diagnosis was bilateral patellofemoral syndrome.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain, bilateral knees and left ankle condition 0%, coded 5099-5003 (Arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA rated the left knee pain condition 10%, coded 5010-5261 (leg, limitation of extension) and the right knee pain condition 10%, coded 5010-5260 (leg, limitation of flexion) based on the C&P examination 11 months after separation, citing painful motion, bilaterally.  

The panel first considered if the each knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards, were implicated by the NARSUM, and profiled.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Panel members agreed the evidence reasonably justified that the functional limitations of the right and left knee condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  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, the NARSUM examination did show evidence of functional loss due to pain supporting a 10% rating for each knee (based on §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition and 10% for the right knee condition, coded 5099-5003.  

Left Ankle Pain.  According to STR and the MEB NARSUM, the CI’s left ankle condition began in 2004 during physical training after twisting the ankle.  During the 6 June 2005 Primary Care appointment, the CI complained of left ankle pain.  X-ray studies on 7 June 2005 showed normal alignment of the ankle, with no fracture, or bony articular abnormality present.  The soft tissue structures of the ankle were normal.  The 17 June 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of chronic ankle pain.  The pain was aggravated by running, prolonged walking or carrying heavy loads.  Physical examination of the left ankle showed there was no edema, tenderness, redness or swelling.  On examination the left ankle range of motion (ROM) following repetition showed dorsiflexion of 25 degrees (normal 20) and plantar flexion of 30 degrees (normal 45).  There was no pain or tenderness with either of these movements and a diagnoses of chronic intermittent left ankle pain was rendered.  At the 1 August 2006 VA C&P evaluation, 11 months after separation, the CI reported daily left ankle pain and inability.  The CI reported no previous surgeries and did not require a brace, cane or other assistive device.  Physical examination showed examination, his left ankle had 5/5 motor strength.  On examination ROM following repetition showed dorsiflexion of 25 degrees (normal 20) and plantar flexion of 40 degrees (normal 45) with no pain during repetitive testing.  There were no additional limitations by pain, fatigue, weakness, or lack of endurance following repetitive use.  X-ray evidence revealed small corticated fragments over the lateral aspect of ankle may have been related to prior trauma.  Examiner's impression was left ankle strain with x-ray evidence of prior trauma.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee and left ankle condition 0%, coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA rated the left ankle condition 0%, coded 5271 (ankle, limited motion), based on the C&P examination 11 months after separation, citing no evidence of moderate limited motion of the ankle.  

The panel first considered if the ankle, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, ankle was considered to fail retention standards, were implicated by the NARSUM, and profiled.  The panel then considered rating under the diagnostic code 5271, limited ankle motion.  There was no limitation of motion of the ankle joint to support a rating under diagnostic code 5271 (limitation of motion) and the MEB and VA C&P examinations did not note the presence of painful joint motion.  The gait was normal and there was no evidence of functional loss that would impact functioning in the average civil occupation.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable or not advantageous to rating.  The limitation of ankle motion described by the MEB and the VA C&P examinations was slight and did not approach the “moderate” stipulation required for a 10% rating under diagnostic code 5271 for limitation of ankle motion.  The panel agreed that the ROM evaluations with a normal gait at the time of the proximate MEB examinations best reflected the condition at separation, and were not consistent with the “moderate” limitation of motion required for the 10% rating under the 5271 code.  There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus), and no astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274).  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 adjudication for the left ankle condition of 0%.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain condition, the panel unanimously recommends a disability rating of 10% for each knee, a combined 20%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left ankle condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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	
Left Knee Pain	5099-5003	10%	
Right Knee Pain	5099-5003	10%	
Left Ankle Pain	5271	0%	
COMBINED	20%	

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 Treatment Record  

AR20180005736, 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