RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01850
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Power Station Electrician, medically separated for “chronic pain secondary to bilateral patellar instability” with a disability rating of 0%.  

CI CONTENTION:  “Original assessment was based on a bilateral rating.  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 - 20050104	VARD - 20051024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Secondary to Bilateral Patellar Instability	5257	0%	Right Knee, Post/Operative X2	5259	0%	STR	
			Left Knee, Post/Operative	5259	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Pain Secondary to Bilateral Patellar Instability.  The PEB combined the right and left knee conditions under a single disability rating, coded 5257 and rated 0%.  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’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 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 underwent arthroscopic debridement with abrasion chondroplasty of his right knee in August 2002, followed by a second arthroscopy with lateral and medial release in March 2003 for chronic patella subluxation.  He also had left knee arthroscopic surgery with open medial patellofemoral ligament repair in March 2004 for patellar instability.  Post-operatively, he had “some resolution of his symptomatology” on the right knee, and “initially he did well” on the left, but he developed increased pain in both knees that impacted military duties.  At the 23 June 2004 orthopedic clinic appointment, the examiner noted “stable patella; no lateral instability.” 

During the 19 September 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported bilateral knee pain, inability to squat or kneel, and that his knees gave out.  Physical examination revealed that he was unable to fully extend or flex his knee.  Specific range of motion (ROM) measurements were not provided other than the examiner noting he was able to flex 90 degrees on the left side.  He had mild edema and 2+ reflexes bilaterally, and was unable to tandem or heel-to-toe walk secondary to pain.  There was no report of instability in either knee.

The 26 October 2004 MEB NARSUM examination, 6 months before separation, noted CI complaints of daily, persistent anterior knee pain that required him to frequently apply ice.  He was unable to run and had difficulty with rough terrain, but denied locking or giving way.  Physical examination showed “good bulk and tone” and “good range of motion” bilaterally in the lower extremities.  He had some tenderness bilaterally in the region of the scars, which were well-healed, but no effusion.  There was some patellar grind, but both knees were stable to varus and valgus stresses, with a 1A Lachman and negative pivot shift.  The CI could heel-toe walk across the office, however he had some anterior knee pain when getting into a full squat, and needed to hold onto the table to get back up due to pain.  

During a physical therapy ROM study on 17 December 2004, the provider noted the CI had a normal gait but wore knee braces when he arrived for the visit.  Measured ROM (without the braces) showed flexion to 138 degrees (normal 140) and extension to 0 degrees (normal) on the right; and flexion to 125 degrees and extension to 0 degrees on the left; painful motion was not addressed.  There was no VA examination proximate to separation in evidence.  

The panel first considered whether each knee condition, when decoupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were considered to fail retention standards and were implicated in the NARSUM.  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.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with military specialty performance, members agreed that each knee was reasonably justified as separately unfitting.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right and left knee conditions and applied a single 0% rating, coded 5257 (knee, other impairment of- recurrent subluxation or lateral instability).  The VA rated the right and left knees 0% each, both coded 5259 (cartilage, semilunar, removal of, symptomatic), based on the STR, citing failure to report for an evaluation which might have provided additional information.  Panel members considered that the objective findings and associated disability for each knee were nearly identical and agreed that the respective ratings should therefore be the same.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45), and 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.  Additionally, there was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); no history of surgery to remove a meniscus (5259); and 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).  No additional functional limitation was evidenced by the examinations.  The panel considered the use of code 5257, but the orthopedic examiner stated there was no lateral instability, and the MEB examinations also did not document any instability or recurrent subluxation for a rating higher than 0% for either knee.  Members agreed that while separate unfit determinations with disability ratings of 0% for each knee condition is appropriately recommended in this case, this results in no rating benefit to the CI.  After due deliberation, considering all of 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.  

BOARD FINDINGS: In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170310, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010720, 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.

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

Sincerely,					      
Enclosure