RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03126
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “bilateral knee pain” with a disability rating of 10%.  

CI CONTENTION:  In addition to the bilateral knee pain, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was requested.  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20070927	VARD - 20080422	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Patellofemoral Syndrome, Right Knee	5299-5260	10%	20070724	
			Patellofemoral Syndrome, Left Knee	5299-5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 below, with 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 pain began in July 2006 after executing a FAST rope departure from a helicopter and landing on his knees.  MRI of the right knee in February 2007 revealed possible results of trauma in the knee joint, with small fluid buildup in the joint (effusion) and folding of the tissue lining the knee joint (plica).  

At the 24 July 2007 VA Compensation and Pension (C&P) examination, 5 months prior to separation, the CI complained of daily bilateral knee pain and locking, brought on by running (which also precipitated knee locking) or descending stairs, rated 4/10 in severity on a daily basis with flares to 7/10.  Physical examination showed normal gait and posture, with no aids used for walking.  The right and left knees were tender, but the CI was able to complete a full standing squat without pain.  The examiner recorded range of motion (ROM) as flexion of 130 degrees (normal 140) and extension to 0 degrees (normal) with mild crepitus (a popping or crackling noise or sensation with movement).  Left knee ROM was recorded as flexion to 122 degrees and extension to 0 degrees with mild crepitus.  Both knees were tender, and the examiner stated (for each knee) under:  “Although the veteran did complain of pain, there is no change in ROM with repetition.  Therefore, I would need to resort to speculation to assess any loss of function due to this pain.  No other criteria.”  

The 15 August 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of bilateral knee pain.  Physical examination referred to the VA examination (above), with a final diagnosis of bilateral patellofemoral pain syndrome.  At the 16 August 2007 physical therapy (PT) MEB ROM study, the CI complained of bilateral knee pain rated 5/10 in severity.  Physical examination showed normal gait and posture.  The right and left knees were tender, but the CI was able to complete a full standing squat without pain.  The examiner recorded ROM for both the left and right knee as 0-140 (normal), with no limitation due to pain.  Muscle strength was normal (5/5) and pain-free.  

The panel directed attention to its rating recommendation based on the above evidence.  As discussed above, the PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 citing slight and frequent pain IAW the USAPDA pain policy.  The VA rated each knee condition 10%, analogously coded 5299-5260 (leg, limitation of flexion), based on the C&P examination, citing functional loss due to pain for each knee.  

The panel first considered whether each knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The profile listed “patellofemoral pain syndrome,” permanently coded L3.  The commander’s statement did not specifically implicate either knee, but instead referred generally to “disability,” “physical impairment,” and “injury,” leading to inability to road march, carry a fighting load or perform the APFT.  The NARSUM implicated both knees and the MEB judged the bilateral patellofemoral syndrome as failing retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the unbundled left and right knee conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting left and right knee conditions 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) 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.  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 knee.  The panel deliberated if there was sufficient evidence of painful motion with functional loss to support a 10% rating for either knee (based on §4.59, §4.40 and §4.45).  The C&P examination indicated crepitus with complaint of pain with motion, but did not specify objective evidence of painful motion.  The PT evaluation was closer to separation and documented no pain-limited motion and no pain with squatting.  The panel majority agreed that a 0% rating was warranted for the right knee if separated from the bundled bilateral knee condition, and the left knee was not ratable above 10%.  However, this provided no rating advantage to the CI.  The panel considered alternative VASRD knee and analogous codes, but all were less applicable and/or not advantageous to rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority 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 majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification to 20%, but did not elect to submit a minority opinion.  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:

[AR NUMBER], 

Dear XXXXXXXXXXXXXXXX:

	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.

Enclosure