RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04403
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050301

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

CI CONTENTION:  He received a higher rating for his conditions from the VA.  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 - 20050201	VARD - 20050314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee and Bilateral Feet	5099-5003	10%	Chondromalacia, Left Knee	5260	10%	20050224	
			Bilateral Pes Planovalgus with Hallux Valgus/Bunion	5276	10%	20050224	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pain, Left Knee and Bilateral Feet.  The PEB combined the left knee and the left and right foot conditions under a single disability rating, coded analogously to 5003 and rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 knee and the bilateral foot conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating, if indicated.  

Left Knee.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in October 2002 with a history of vague knee pain.  A bone scan and X-rays were both normal.  In orthopedics on 17 October 2003, he was noted to have bilateral medial joint line tenderness.  Left knee range of motion (ROM) was full and stable.  An orthopedics evaluation on 6 January 2004 revealed plica (entrapment of soft tissue in the joint).  Arthroscopic surgery was performed on 10 March 2004 which removed the plica.  Although his symptoms improved he continued to have knee and foot pain.

The 16 December 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of ongoing left knee pain which limited activity.  Physical examination showed left knee tenderness and crepitus.  There were was no meniscal irritation or ligament instability.  Left knee extension was 0 degrees (normal) and flexion was 130 degrees (normal 140); painful motion was present.  During the MEB examination (recorded on DD Forms 2807-1 and 2808), less than a week later, the CI reported knee pain.  Physical examination showed left knee tenderness but no laxity, swelling, locking, or meniscal irritation.

At the 24 February 2005 VA Compensation and Pension (C&P) general examination, one week before separation, the CI reported chronic left knee pain which impaired physical activity.  Physical examination recorded a normal gait with no left knee swelling or locking.  No assistive device was in use.  The left knee stability and meniscal testing was negative.  Extension was 0 degrees and flexion was 135 degrees; painful motion was not recorded but mild crepitus was noted.  Repetition caused no further limitation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee and bilateral feet conditions 10%, analogously coded 5099-5003 (arthritis, degenerative) citing application of the USAPDA pain policy and AR 635-40 B24.f.  The VA rated the left knee condition 10%, coded 5260 (leg, limitation of flexion), based on the C&P general examination, citing painful motion.

The panel first considered if the left knee was separately unfitting after decoupling it from the bilateral foot condition.  It was implicated by the commander’s statement, profiled, and found medically unacceptable by the MEB.  The evidence supported a recommendation that the left knee was separately unfitting at separation.  The panel then considered the rating recommendation for the unfitting left knee condition.

The panel agreed there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was sufficient STR evidence of painful motion with functional loss supporting a 10% rating (based on VASRD §§4.59, 4.40 and 4.45).  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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition, coded 5260.

Bilateral Feet.  According to the STR and MEB NARSUM, the CI’s bilateral foot condition began in late 2001.  He was diagnosed with symptomatic pes planus (flat feet) as well as plantar fasciitis and treated with duty limitations and medications.  A bone scan in October 2002 was significant for old healed ankle injuries, but feet and plantar fascia were negative.  Over the course of the next 2 years, the CI noted progressive bilateral foot pain.  He was diagnosed with chronic plantar fasciitis.  An orthopedics examination on 13 December 2004 noted bilateral foot pain and pain with motion.  The MEB NARSUM examination, 3 days later, noted complaints of bilateral foot pain with no specific foot examination findings.  During the 22 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), the examiner recorded bilateral symptomatic pes planus.  

At the 24 February 2005 C&P examination, 1 week before separation, the CI reported chronic bilateral plantar fasciitis.  Gait and posture were normal.  Pes planus was present on the left but not the right.  Tenderness of the plantar fascia was not present.  No obvious limitations in function were found.  X-rays showed bilateral pes planus with bilateral bunions.  The CI was diagnosed with bilateral pes planovalgus with bunions.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee and bilateral feet conditions 10%, analogously coded 5099-5003 (degenerative arthritis) citing application of the USAPDA pain policy and AR 635-40 B24.f.  The VA rated the bilateral foot condition 10%, coded 5276 (flatfoot, acquired), based on the C&P general examination, citing pain on manipulation and use of the feet.  The panel first considered if the bilateral foot condition was separately unfitting after decoupling it from the left knee.  It was not commented upon by the commander, but it was profiled and found medically unacceptable by the MEB.  The evidence supported a recommendation that the bilateral foot condition was separately unfitting at separation.  The panel then considered the rating recommendation for the unfitting bilateral foot condition.  The panel agreed that numerous STR examinations noted limitations in activity due to foot pain.  Pes planus was diagnosed by multiple examiners, was symptomatic, and revealed by objective X-ray findings.  Panel members agreed the evidence supports a 10% rating for bilateral pes planus at the “moderate” level.  There was no evidence of marked deformity, swelling on use, and characteristic callosities for a higher rating.  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 bilateral feet condition, coded 5276.

BOARD FINDINGS:  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5260 IAW VASRD §4.71a.  In the matter of the bilateral feet condition, the panel recommends a disability rating of 10%, coded 5276 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	
Chronic Pain, Left Knee	5260	10%	
Chronic Pain, Bilateral Feet	5276	10%	
COMBINED	20%	
The following documentary evidence was considered:

AR20190004844, XXXXXXXXXX

Dear XXXXXXXXXX:

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.