RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04939
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, E3, Power Generator Repairer, medically separated for “bilateral knee pain” with a disability rating of 0%.   

CI CONTENTION:  He received a higher rating for the knee pain by the VA, and also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 - 20051102	VARD - 20060331	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Retropatellar Pain Syndrome, Left Knee 	5260	0%	20060124	
			Retropatellar Pain Syndrome, Right Knee 	5260	0%	20060124	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 (arthritis, degenerative) and rated 0%.  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 separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

Left Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in January 2005 after falling and twisting his knee.  However, a treatment note on 9 February 2005 also indicated he had left knee pain for 2 days while running during a ruck march.  A left knee MRI in April 2005 showed mild chondromalacia patella, inflammation and edema within Hoffa’s fat pad adjacent to the inferolateral patella, and degeneration of the posterior horn of the medial meniscus. Despite rest, medication, and physical therapy, symptoms persisted. A note dated 13 July 2005 indicated the CI received a steroid injection 3 weeks earlier and was given a neoprene knee support.  

During the 26 July 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported chronic knee pain.  The examiner recorded increased crepitus (grinding sensation) in both knees with a positive patella apprehension test, left greater than right.  There was no joint line pain or instability, and bilateral range of motion (ROM) was full.

The 7 September 2005 MEB NARSUM examination, 6 months before separation, noted CI complaints of knee pain and constant aching and burning behind the left knee more than the right.   Physical examination showed a normal gait with no effusion or joint line tenderness.  There was pain with patellar grinding, but no laxity or instability.  The ROM was full without evidence of painful motion, and provocative testing to elicit meniscal pathology was negative.

A treatment note on 20 October 2005 indicated the CI slipped while walking down a hill and hyperextended his left knee.  However, other than a bump on top of the bone a few inches below the knee, and decreased ROM, there was no bruising, instability (negative drawer tests), or evidence of a meniscal tear.  Leg X-rays showed a small calcific density in the subcutaneous tissues just superior to the patella, but no evidence of a fracture or dislocation.  

At the 24 January 2006 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported intermittent pain with overuse, but denied incapacitation or functional impairment.  Physical examination showed a normal gait without signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement.  The ROM measurements showed flexion of 140 degrees (normal) and extension of 0 degrees (normal).  There was no limitation of motion due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Provocative testing showed ligamentous instability less than 5 mm and no meniscal pathology; X-rays were normal.

The panel first considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled left knee condition was reasonably considered separately unfitting.  

The panel then directed attention to its rating recommendation for the unfitting left knee condition at the time of separation.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003, citing minimal and frequent pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the left knee condition 0%, coded 5260 (limitation of leg flexion), based on the C&P examination, citing full ROM.  Members agreed there was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of flexion or extension which attained a 10% rating under 5260 or 5261.  There was no history or evidence of dislocated meniscus, loose body causing frequent locking with recurrent effusions (5258); history of surgery to remove a meniscus (5259); or 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).  No additional functional limitation was evidenced by the examinations.  Therefore, the panel concluded there was not sufficient evidence to support a rating higher than the 0% for the left knee condition.  

Right Knee Pain.  According to the STR and MEB NARSUM, the CI’s right knee condition began in March 2005 without evidence of trauma or injury, but as a result of compensation for the left knee injury.  Radiographic studies showed “patellar tendonitis, posterior horn of the medial meniscus degeneration or tear, and an intercondylar pericruciate cyst [which arises from a tear of the medial meniscus].”  At a physical therapy evaluation on 11 May 2005, the CI complained of knee pain greater on the left than the right.  The right knee was not tender and ROM was 0-130 degrees.  Despite physical therapy and medication, the right knee pain persisted.  

The MEB and NARSUM examination findings for the right knee mirrored those of the left knee discussed above, with evidence of crepitus, but no joint line pain, instability or meniscal pathology.  Measured ROM was full and without painful motion.  

The VA C&P examination also indicated the same physical findings for the right knee as already mentioned, with ROM from 0-140 degrees, and no limitation of motion due to pain, fatigue, weakness, lack of endurance or incoordination after repetitive use; X-rays were normal.

The panel considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled right knee condition was reasonably considered separately unfitting.  

The panel then directed attention to its rating recommendation for the unfitting right knee condition at the time of separation.  The PEB rated the bilateral knee condition 0% as noted above.  The VA rated the right knee condition 0%, coded 5260, based on the C&P examination, citing full ROM.  Members agreed there was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of flexion or extension which attained a 10% rating under 5260 or 5261.  There was no history or evidence of dislocated meniscus, loose body causing frequent locking with recurrent effusions (5258); history of surgery to remove a meniscus (5259); or 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).  No additional functional limitation was evidenced by the examinations.  Therefore, the panel concluded there was not sufficient evidence to support a rating higher than the 0% for the left knee condition.  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 pain condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain 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.  

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XXXXXXXXXX
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Dear XXXXXXXXXX:

	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