RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-01561
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050523

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

CI CONTENTION:  “Plantar fasciitis, L[eft] ankle, both knees should have been considered and are worse than was stated from the board.”  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 - 20050404	VARD - 20051219	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Retropatellar Pain Syndrome	5099-5003	0%	Patellofemoral Syndrome-Left	5099-5003	10%	20050718	
			Patellofemoral Syndrome-Right	5099-5003	10%	20050718	
Plantar Fasciitis	Not Unfitting	Plantar Fasciitis	5299-5278	10%	20050718	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Bilateral Retropatellar Pain Syndrome.  The PEB combined the right and left knee conditions under a single 0% disability rating, coded analogously to 5003.  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 is presented together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee pain began in October 2003 after participating in physical training runs.  X-rays of the knees showed no demonstrable evidence of premature degenerative changes or any other significant findings.  At the orthopedic clinic examination on 16 February 2005, 3 months before separation, the CI complained of bilateral knee pain, which prevented him from completing the Army fitness test.  Physical examination showed full right knee range of motion (ROM) without effusion, instability or laxity about the knee.  No examination of the left knee was noted.  The examiner’s impression was right retropatellar pain syndrome.  

During an orthopedic consultation for the MEB dated 25 February 2005, 3 months prior to separation, the CI complained of knee pain localized to the retropatellar region aggravated by stairs or sitting or standing for long periods of time.  On examination, there was full ROM without effusion, instability or laxity.  There was retropatellar crepitus (grinding sensation) and positive quadriceps inhibition testing.  The examiner’s diagnosis was bilateral retropatellar syndrome.  The commander’s statement referred to a P3 profile for chronic bilateral knee pain issued in February 2005 since the CI could not run, jump, march or perform the myriad of physical tasks required of a soldier.  

At the 14 March 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported chronic bilateral knee pain.  Physical examination of both knees revealed no effusion, instability or meniscal signs, but patellar apprehension testing was painful bilaterally.  Active extension-to-flexion ROM of the right knee was 0-130 degrees (normal 0-140) and the left knee was 0-115 degrees.  The 22 March 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of constant 7/10 knee pain aggravated by climbing steps, hills, carrying ruck sacks, doing “3 to 5 second rushes” and running.  The CI reported no swelling, locking or instability.  Physical examination referred to the orthopedic examination of 25 February 2005 and incorporated ROM measurements from the 14 March 2005 MEB physical examination.  A permanent L3 profile for chronic knee pain was approved on 30 March 2005. 

At the 18 July 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported pain with prolonged standing and walking.  Physical examination showed tenderness of the patella bilaterally.  The bilateral ROM study showed flexion of 145 degrees and extension of 0 degrees without pain. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral retropatellar pain condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing no loss of joint motion.  The VA rated the bilateral retropatellar pain 10% for the right knee and 10% for the left knee, with each knee analogously coded 5099-5003, based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  The panel first considered if the left and right knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Members agreed the left and right knee conditions were reasonably justified as separately unfitting.  Accordingly, each knee should be afforded a separate disability rating.  

The panel noted there was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for either knee.  There likewise was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for either knee.  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 for either knee.  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) for either leg.  No additional functional limitation was evidenced by the examinations.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than the 0% for either knee.  The panel then considered whether a 10% or higher rating for both knees was applicable using code 5003 in the absence of limitation of motion.  However, use of code 5003 requires X-ray evidence of arthritis involvement of two or more major joints, which was not noted on X-rays of the bilateral knees.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than the 0% for either knee.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

Contended PEB Condition:  Plantar Fasciitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not permanently profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition, so no additional disability rating is recommended.    

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended plantar fasciitis, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

AR20190002387, XXXXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXXXX:

	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.  

A copy of this decision has been provided to the counsel you listed on your application.