RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xxxxxxxxxxxxxxxxx	CASE:  PD-2017-05066
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060418

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “bilateral knee pain” with a disability rating of 0%.  

CI CONTENTION:  “My injury is always getting worse and it effects my everyday life.”  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 - 20060314	VARD - 20060508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Stress Reaction, Left Medial Knee	5299-5262	10%	STR	
			Stress Reaction, Right Medial Knee	5299-5262	10%	STR	
COMBINED RATING:  0%	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, analogously coded 5003 (degenerative arthritis) and rated 0%, 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 of the PEB.  The evidence for the right and left knee conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began in July 2005 early on in his initial entry training.  He was recycled due to the bilateral knee pain, which interfered with his ability to run, march and participate in other strenuous activities.  X-rays of the bilateral tibia and fibula revealed lower extremity edema but no bony changes.  Bone scan showed increased uptake of bilateral medial tibial plateaus and bilateral calcanei.  During the physical therapy (PT) clinic appointment on 17 August 2005, 8 months prior to separation, the CI reported bilateral anterior knee pain.  On examination there was tenderness of the bilateral medial tibial plateaus and bilateral talar domes.  The CI was placed on activity restrictions.  

At the PT clinic appointment on 29 November 2005, 5 months prior to separation, the CI reported his bilateral knee pain had resolved and requested return to duty.  He had been able to run without pain.  On examination the CI walked with a normal gait and there was no swelling, no fluid and no redness.  However, during the PT clinic appointment on 24 January 2006, 3 months prior to separation, the CI reported bilateral knee pain from day one of starting back into training.  On examination there was tenderness at the medial tibial plateaus with negative fluid and negative patellar compression.  X-rays appeared normal.  

The 3 February 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral knee pain.  Physical examination showed comfortable appearing bilateral knees and normal examination with full range of motion (ROM), no fluid, no deformity and normal strength.  The CI had minimal tenderness and walked with a normal gait.  X-rays of bilateral knees and legs were normal, but a bone scan in January 2006 showing increased uptake of bilateral medial knees.  The examiner stated the CI’s “condition as a Basic Trainee requires that he be able to run, march, and perform other strenuous activities.  Because of the functional limitations and pain associated with his condition, he cannot perform his duties.”  During the 14 February 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported bilateral knee stress fractures.  Physical examination revealed tenderness of the upper one third of the tibias.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5003, citing slight and intermittent pain IAW the USAPDA pain policy.  The VA rated the right and left knee conditions 10% each, analogously coded 5262 (tibia and fibula, impairment), based on the STR, citing painful motion for each knee.  As previously elaborated, the panel must first consider whether the left and right knee conditions remained separately unfitting after being de-coupled from the combined PEB adjudication.  The bilateral knee conditions were permanently profiled, implicated in the commander’s statement and the NARSUM and judged to failed retention standards.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with continued training, members agreed that each knee was reasonably justified as separately unfitting.  

There was no limitation of motion which attained a 10% 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 for either knee.  There was no fracture, nonunion or malunion of the femur to support consideration under the 5255 (femur impairment) code for either leg.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59) for either knee.  Given the evidence of chronic bilateral tibial stress reactions, the panel considered analogous ratings under code 5262.  The NARSUM and MEB examinations documented bilateral knee and/or tibial tenderness with “functional limitations and pain.”  Therefore, the panel agreed this evidence best represented the 10% (slight) knee disability criteria under code 5262.  There was insufficient evidence to support moderate disability for either knee under code 5262.  After due deliberation, and considering all the evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5299-5262.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5299-5262 and rated 10%, and an unfitting left knee condition coded 5299-5262 and rated 10%, both 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	
Right Knee Pain 	5299-5262	10%	
Left Knee Pain 	5299-5262	10%	
COMBINED	20%	

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Dear XXXXXXXXXXXXXXXXXXXXXX:

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.