RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-02265
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20040331

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Heavy Wheeled Vehicle Mechanic, medically separated for “bilateral retropatellar pain syndrome” 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 – 20040203	VARD – 20050128	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Bilateral Retropatellar Pain Syndrome	
5099-5003	
0%	Right Tibial Stress Fracture with Right Knee Strain	5262	10%	
20041019	
			Left Tibial Stress Fracture with Left Knee Strain	5262	10%		
Mild Hearing Loss Left Ear	Not Unfitting	Bilateral Hearing Loss	6100	0%		
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Bilateral Retropatellar Pain Syndrome. The PEB combined the right and left knee conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) 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. The evidence for the right and left knee conditions is presented together, followed by attendant recommendations regarding separate unfitness and separate rating if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began as early as March 2001 without precipitating trauma or injury. Bone scans in 2002 showed an area of overuse in the left tibial plateau and distal femur and a stress fracture of the right mid tibia. Bilateral leg X-rays in 2002 showed a stress fracture of the right mid-tibia, but in October 2003, radiographic studies were unremarkable for both knees. A profile dated 5 November 2003 listed bilateral knee pain, and the commander’s statement on 17 November 2003 implicated both knees as impairing the CI’s duty performance.

The 8 October 2003 MEB NARSUM examination, 6 months prior to separation, noted complaints of bilateral anterior knee pain, left greater than right, which was exacerbated by going down stairs and limited standing, kneeling, crawling and running for long periods. Physical examination showed no tenderness or effusion, and range of motion (ROM) was described as full (normal 0- 140 degrees).  Patellar grind tests were “significantly positive” for each knee.

At the 19 October 2004 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported constant, sharp knee pain, worsened with activity, which prevented extended standing, sitting, running, jumping, crouching, kneeling, or walking. Physical examination showed normal posture, gait (although slow) and knees. Bilateral knee ROM was 0- 140 degrees, with painful motion noted with flexion. There was additional fatigue, weakness, lack of endurance and incoordination with repetition of each knee, but pain had the major impact on function. There was tenderness of both shins without malunion or nonunion. Bilateral knee X- rays showed no evidence of arthritis, and bilateral tibia/fibula X-rays were normal.

The panel first considered whether the individual knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. Both knees were profiled and implicated by the commander’s statement, and failed retention standards. The panel concluded there was not a preponderance of evidence in the service records which overcame the presumption that each of the bundled knee conditions was reasonably considered separately unfitting. The panel next considered its rating recommendation for the unfitting individual knee conditions at the time of separation.

The PEB rated the bundled knee condition 0%, coded 5099-5003 as mentioned above. The VA rated each leg (for tibial stress fractures with knee strain) 10%, coded 5262 (tibia-fibula impairment), based on the C&P examination, citing tibia/fibula malunion with slight disability. The VA C&P examination was 7 months after separation, and therefore the panel majority placed greater probative value on the MEB NARSUM examination for its rating recommendation. There was no evidence of painful motion with functional loss of either knee to support a 10% rating (based on §4.59, §4.40 and §4.45), and likewise was no limitation of flexion or extension of either knee which attained a 10% rating under codes 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), and no nonunion or malunion of either femur or tibia to support consideration under the respective codes for knee impairment related    to long

bone conditions (5255, 5262). No additional functional limitation of either knee was documented, and therefore the panel majority concluded there was insufficient evidence to support a rating higher than 0% for either knee. After unbundling the knees, the panel majority recommends a 0% combined rating for the knees and therefore no change to the PEB 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 pain condition.

Contended PEB Condition: Mild Left Ear Hearing Loss. 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 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 retropatellar pain syndrome and IAW VASRD
§4.71a, the panel majority recommends no change in the PEB adjudication. The single voter for dissent recommends modification to 10% for each knee, both coded 5299-5260 IAW VASRD
§4.71a, but did not elect to submit a minority opinion. In the matter of the contended mild left ear hearing loss, 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.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170413, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20190007783, 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