RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03984
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050918

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Parachute Rigger, medically separated for “bilateral knee pain” with a disability rating of 0%.

CI CONTENTION:  “Rating should have been higher prior to discharge.”  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 - 20050713	VARD - 20051229	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Retropatellar Pain Syndrome, Left Knee	5019-5010	10%	20050729	
			Retropatellar Pain Syndrome, Right Knee	5019-5010	10%	20050729	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency 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, it may not recommend a lower combined rating than that of the PEB.  

Bilateral Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a right knee injury during a jumping incident in August 2002 when he landed on his rucksuck.  A bone scan on 14 March 2005 showed mild posttraumatic changes in the right patella and the right lateral tibial plateau region.  There were moderate posttraumatic changes in the left knee fibular head region.  

During the 6 May 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported “knee is in pain every day.”  Physical examination of the right knee showed no edema, but exquisite tenderness to palpation of the infrapatellar tendon.  There was no crepitus, crunchy or grinding with flexion or extension, but pain was reported with full flexion.  

The 12 May 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of right knee pain.  Physical examination was unremarkable with the exception of some tenderness of the infrapatellar tendon bilaterally without patellar grind or crepitus.  The examiner referred to the orthopedic specialty consult and the MEB PT ROM evaluation that noted an inclinometer was utilized for ROM, which was not IAW VASRD 4.46.  At the 17 May 2005 physical therapy MEB ROM evaluation, 4 months prior to separation, the right knee range of motion (ROM) following repetitive movement was flexion of 125 degrees (normal 140) and extension of 0 degrees (normal).  Left knee ROM was flexion of 130 degrees and extension of 0 degrees.  Limitation of flexion in both knees was due to pain.  

During the 25 May 2005 orthopedic specialty consult for the MEB, the CI stated “I have severe pain in my right knee.”  The examiner noted normal X-rays of the right knee and the bone scan findings which showed slight increase uptake in the right patella and right lateral tibial plateau, which could be possibly due to some minor recent trauma.  Physical examination showed a normal gait and no effusion.  There was moderate crepitation of his patellofemoral joint and irritation of the patellofemoral joints, greater on the right.  There was full ROM of both knees.  

At the 29 July 2005 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported twisting his knees when he landed on his rucksack during a parachute jump.  The CI stated he returned to full duty without complications.  Physical examination showed a normal gait without effusion.  Both the left and right knee range of motion (ROM) was flexion of 140 degrees (normal 140) and extension of 0 degrees (normal 0).  Pain, weakness, lack of endurance, fatigue or incoordination did not impact further on the ROM after repetitive use.  X-rays were normal.  The examiner stated no pathology was identified on physical examination to render a diagnosis.  

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 analogously to 5003 (degenerative arthritis).  The VA rated each knee condition 10%, dual coded 5019-5010 (bursitis-arthritis due to trauma) based on the C&P examination, citing post traumatic changes in both knees.  

The panel first considered if the right knee condition met the panel’s threshold for separate rating (as elaborated above).  Panel members agreed the evidence reasonably justified that the right knee functional limitations contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  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 §4.59, §4.40 and §4.45.  

The panel next considered the left knee condition.  The STR evidence only referenced treatment for right knee complaints.  The MEB referred bilateral knee pain, right greater than left, and the profile listed chronic knee pain.  However, the commander only mentioned right knee pain and the only mention of the left knee were findings on the bone scan.  Based on the above evidence, there was a questionable basis for arguing that the left knee was separately unfitting. The well-established principle for fitness determinations is that they are performance-based. The panel could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference due to the left knee with the performance of duties at the time of separation.  Members agreed the preponderance of the evidence did not support a conclusion that the functional impairment from the left knee was integral to the CI’s inability to perform his military duties (is not unfitting) and accordingly cannot recommend a separate rating for it.  Based on the totality of evidence, the panel agreed the right knee should be rated at 10% for painful motion founded in the STR.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends that it be adjudicated for two separate conditions, in the matter of the right knee condition, the panel recommends a separately unfit determination with a disability rating of 10%, coded 5003.  In the matter of the left knee condition, the panel agreed that it cannot recommend a finding of unfit for additional disability rating.  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	
Right Knee Pain	5099-5003	10%	

AR20180015898, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear  XXXXXXXXXXXXXXXXXX

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.