RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-02414
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060614

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Light Wheeled Vehicle Mechanic, medically separated for “chronic bilateral retropatellar pain syndrome with degenerative changes” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made.  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 - 20060501	VARD - 20050421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Retropatellar Pain Syndrome	5099-
5003	10%	Left Knee Mild Degenerative Joint Disease (DJD) with Residuals	5003	10%	20050124	
			Right Knee Mild DJD with Residuals	5003	10%	20050124	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Chronic Bilateral Retropatellar Pain Syndrome. The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10%. 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 left and right knee 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 knee condition began in July 2003 while deployed to Afghanistan, where his knee pain significantly worsened. Bilateral knee X-rays in April 2006 showed evidence of degenerative changes.  There were no surgical indications for his condition.

At the 24 January 2005 VA Compensation and Pension (C&P) examination, 17 months before separation, the CI reported bilateral knee pain at the lateral aspect of the knees. Physical examination showed a normal gait with tenderness in both knees. There was no effusion, muscle atrophy, spasm, instability, or crepitation. McMurray's test was negative (for meniscal signs). On examination, the bilateral knee range of motion (ROM) was flexion of 140 degrees (normal) and extension of 0 degrees (normal), with no additional loss of motion due to pain or weakness.

The 4 April 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of constant bilateral knee pain which he rated as 4/10. He had worsening to 10/10 with prolonged walking, climbing stairs, kneeling, squatting, walking on uneven surfaces, and with impact activities. Physical examination showed tenderness, and retropatellar grind with right being greater than left. McMurray's test was negative. The left and right knee range of motion (ROM) following repetitive movement was flexion of 130 on the left and 125 degrees on the right; extension was 2 on the left and 0 degrees on the right, and limited by pain on each knee.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB bundled the right and left knees and applied a single 10% rating, coded 5099-5003, citing two joints with positive radiographs. The VA rated the left and right knee conditions 10% each, coded 5003, based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints for each knee.

In this case, both knees were considered to fail retention standards. They were implicated by the NARSUM and the commander’s statement and both were profiled. 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 interfered with the performance of military duties, members agreed that each knee was reasonably justified as separately unfitting.

The panel next directed attention to its rating recommendation based on the above evidence. There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (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) 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). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on VASRD  §§4.59, 4.40 and 4.45) for each knee.   After due deliberation,  and  considering all    the

evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5099-5003.

BOARD FINDINGS: In the matter of the bilateral knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Retropatellar Pain Syndrome	5099-5003	10%	
Right Retropatellar Pain Syndrome	5099-5003	10%	
	COMBINED	20%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170302, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

	PD-2017-02414

AR20190012188, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXX

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 Veterans Affairs.

Sincerely,

Enclosure

	PD-2017-02414