RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04447
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070607

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

CI CONTENTION:  The CI made no specific contention.  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 – 20070417 	VARD – 20080122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Retropatellar Pain Syndrome, Left Knee	5257-5003	10%	20080108	
			Retropatellar Pain Syndrome, Right Knee	5257-5003	10%	20080108	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 and rated 10% 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, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral knee pain is presented together, but 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 condition began in June 2004, during physical fitness training.  X-rays of both knees and an MRI of the right knee were normal, but an MRI of the left knee showed an increased intensity of the medial meniscus without a tear.  The MRIs were repeated on 3 November 2006 and both were normal as were X-rays the same day.  

The 19 March 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of persistent pain, but with some improvement.  The physical examination showed tenderness of both knees, but no swelling.  A grind test (for patellar pathology) was positive.  The range of motion (ROM) was slightly limited in flexion at 0-135 bilaterally (normal 0-140).  Painful motion was not recorded.  The knees were stable.  His symptoms were thought to be suggestive of retropatellar pain syndrome.  

During the 6 May 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 1 month prior to separation, the CI reported progression of his bilateral knee pain.  The physical examination showed normal ROM.  The patellar tendons were tender and there was retropatellar pain with ROM.  The knees were stable with equivocal signs of meniscal irritation.  

At the 8 January 2008 VA Compensation and Pension (C&P) evaluation, 7 months after separation, the CI reported constant knee pain aggravated by activity.  He reported that he had been issued knee braces and did “much walking and climbing” at his current job which entailed visitations to construction sites.  On the physical examination, the gait was normal.  Flexion was limited by pain to 100 degrees on the left and 90 degrees on the right with normal extension.  The knees were stable and signs of meniscal irritation were absent.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing slight/frequent pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the left and right knee conditions 10% each, analogously coded 5257-5003, based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints, and may also be applied once to multiple joints if there is no limited or painful motion.  

The panel first considered if the right and left knees were separately unfitting at separation.  The CI was profiled for bilateral knee pain and both were found to be medically unacceptable by the MEB.  The record showed that the CI was consistently seen for both knees at most appointments and neither was noted to be more impairing than the other.  The evidence supported a finding that each knee was individually unfitting at separation.  The panel then considered the evidence.  Other than one MRI report for the left knee which was remote from separation, the imaging studies were normal.  The ROM noted at the MEB was nearly normal (and 135 is the normal end for flexion used by many physical therapists).  Flexion was limited for both knees at the VA examination, but the gait was normal and the knees were otherwise unremarkable.  It is not clear from the objective evidence why the flexion measured by the VA was so limited, especially given his reported activity level and the MEB values.  The probative value of this examination was thereby reduced and it was not used for rating purposes.  The panel considered the coding options specific for the knee.  None supported a compensable rating.  The 5003 code supports a 10% rating for each knee in the presence of limitation of motion with pain in the setting of X-ray findings.  The X-rays and MRIs proximate to separation were normal.  The panel determined that the evidence supported non-compensable ratings for each knee, but a rating lower than that adjudicated by the PEB is not recommended by the panel.  After due deliberation, considering all of 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 condition.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20170216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006647, 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