RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01992
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “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 - 20050810	VARD - 20061024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain…	5099-5003	0%	RPPS, R Knee	5099-5020	0%	20050929	
			RPPS, L Knee	5099-5020	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain Attributed to Retropatellar Pain Syndrome (RPPS).  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 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 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 MEB narrative summary (NARSUM), the CI’s knee condition began in October 2004 after running and jumping.  Her examination showed tenderness, but normal range of motion (ROM), stable knees, and no signs of meniscal irritation.  She was thought to have a bilateral patello-femoral syndrome and treated with medications and duty limitations.  X-rays on 19 January 2005 of both knees showed mild medial compartment narrowing on the right and a left fabella (a normal variant).  An examination that day noted full ROM and no laxity.  An MRI of the right knee on 16 March 2005 was normal.  A follow-up in physical therapy on 6 May 2005 again noted a normal gait, full ROM, and a stable knee without signs of meniscal irritation.  

Repeat x-rays on 8 June 2005, 5 months prior to separation, showed medial compartment narrowing more prominent on the left, but no signs of arthritis.  During the MEB orthopedic consultation the same day, the CI reported bilateral knee pain with a locking sensation and episodes of buckling, but denied instability.  Physical examination revealed good patellar mobility, no effusion, and no signs of instability.  The ROM for both knees was normal.  There was no comment on painful motion or the gait.  Plain X-rays of bilateral knees revealed no fracture, dislocations, or arthritis.  The MRI showed intact menisci and ligaments.  

The 22 June 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of bilateral knee pain.  Physical examination showed full active ROM with good patellar mobility for both knees.  Examiner noted that the CI had been issued a neoprene knee brace for the right knee in March 2005.  It was noted that patellar compression with quadriceps contraction caused significant pain and the patellae (kneecaps) had tenderness over the inferior pole and along the lateral border.  MRI of the right knee was within normal limits and X-ray of bilateral knees showed bilateral medial compartment narrowing, more prominent on the left.  

At the 29 September 2005 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported bilateral knee pain since October 2004.  Physical examination showed no swelling, effusion, or instability.  There was mild crepitus and tenderness of both patellae.  Gait was abnormal with a limp favoring the right knee.  The ROM for both knees was full with pain beyond 120 degrees flexion bilaterally.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing normal MRI, no joint laxity, and no significant loss of joint motion.  The VA rated the left knee condition 0% and the right knee condition 0%, both analogously coded 5099-5020 (synovitis), based on the STRs and C&P examination, citing normal ROM for both knees  with no effusion or instability for either knee.  The examiner noted that the CI failed to report for an examination scheduled for 19 September 2006.  Both knees were considered to fail retention standards, implicated by the NARSUM and the commander’s statement, and profiled.  Bilateral RPPS was found to be medically unacceptable.  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 performance, members agreed that each knee was reasonably justified as separately unfitting.  

The panel then considered its rating recommendation for each knee at the time of separation.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no instability and no diagnosis of meniscal pathology.  Although motion was painful on the VA examination, it is an outlier as this was not recorded on previous examinations.  One x-ray showed right joint space narrowing and another left joint space narrowing.  The orthopedist thought the x-rays to be unremarkable.  After unbundling the knees the rating for each knee remains 0%, which provides no ratings benefit over the PEB adjudication.  Therefore, no change to the PEB’s combined adjudication is recommended.  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.  

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.  

AR20180016904, 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