RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01214
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20060417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Human Resources Specialist, medically separated for “chronic bilateral knee and lower leg pains” 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 - 20060103	VARD - 20061128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee and Lower Leg Pains	5099-5003	0%	Right Chondromalacia Patella	5299-5257	10%	20060203	
			Left Chondromalacia Patella	5299-5257	10%	20060203	
Bilateral Painful Dorsal Carpal Ganglia	Not Unfitting	Scar, Status Post Right Dorsal Wrist Ganglion Excision	7899-7804	10%	20060203	
		Scar, Status Post Ganglion Excision Left Ring Finger Metacarpal Head	7899-7804	10%	20060203	
		Scar, Status Post Left Dorsal Wrist Ganglion Excision	7899-7804	10%	20060203	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee and Lower Leg Pains.  The PEB combined the left and right knee conditions and left and right leg conditions under a single disability rating, coded analogously to 5003 and rated 0% 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 of the PEB.  The evidence for the bilateral knee and lower leg conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral leg and knee conditions began in 1999 with gradual onset during basic military training.  She was evaluated by multiple orthopedic surgeons, none of whom recommended surgical intervention.  The 4 November 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of bilateral knee pain that was worse with standing, sitting, running, walking, lifting, squatting, kneeling, and climbing stairs.  Physical examination showed tenderness with palpation and compression over the patella, but no joint line tenderness.  There was full range of motion (ROM) with no mention of painful motion.  The examination was silent regarding the bilateral tibiae conditions.  During the 16 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the physical examination showed knee pain with squatting and was silent regarding the bilateral tibiae.

At the 3 February 2006 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI complained of bilateral knee pain precipitated by prolonged sitting, standing, and stairs.  The CI also complained of constant pain to the bilateral shin area.  She stated that she could not walk greater than 15 minutes without flare-ups and that she could not run, play sports, or swim.  Physical examination showed a normal gait with tenderness to the bilateral anterior tibiae.  ROM testing showed flexion to 140 degrees (normal) with stated pain and extension to 0 degrees (normal), also with stated pain.  There was no crepitus noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled bilateral knee and lower leg pain conditions 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing “rated for pain” with application of the USAPDA pain policy.  The VA rated the right and left knee conditions (also claimed as tibia stress fracture and shin splint) 10% each, coded 5299-5257 (analogous to knee, other impairment of), based on the C&P examination, citing recurrent subluxation or lateral instability of the knee which was slight.  

The panel first noted that separately rating the bilateral tibiae would violate the precepts of VASRD §4.14 (Avoidance of Pyramiding) and agreed that any disability from the bilateral tibial stress fractures was properly subsumed in the rating for the bilateral knee conditions.  The panel then considered if the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were listed on the permanent profile and a review of the STR shows that in the three years prior to separation the preponderance of the evidence implicates both knees equally.  The commander’s statement did not implicate any of the conditions and instead stated that none of the conditions were unfitting and argued for retention.  Panel members agreed the evidence reasonably justified that the functional limitations of the right and left knee conditions contributed to the CI’s inability to perform her duties, and accordingly separate disability ratings are recommended for each.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) reported on the VA examination proximate to separation.  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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends separate disability ratings of 10% each for the right and left knee conditions, coded 5099-5003.  

Contended PEB Condition:  Bilateral Painful Dorsal Carpal Ganglia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not implicated in the commander’s statement nor judged to fail retention standards.  Although it was listed on the profile (U2), it was not significantly limiting. The commander stated that the CI’s “duty performance has been outstanding” and did not support medical separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee pain conditions, the panel recommends separate disability ratings of 10% each, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the bilateral lower leg pain condition, the panel agrees that the condition was properly subsumed into the bilateral knee condition and it cannot recommend a finding of unfit for additional disability rating.  In the matter of the contended bilateral painful dorsal ganglia conditions, the panel agrees that it cannot recommend them for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective the date of medical separation:  

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170305, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180004935, 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 Veteran Affairs.

Sincerely,					      
Enclosure