RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-05152 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20071028

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty 03, Transportation Officer, medically separated for “bilateral knee pain” with a disability rating of 10%.

CI CONTENTION: Review requested of sleep apnea, and 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 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 - 20070705	VARD – 20080503	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5003	10%	Left Knee Degenerative Joint Disease (DJD) Status Post Arthroscopy	5010	10%	20070822	
			Right Knee DJD… Arthroscopy	5010	10%	20070822	
Obstructive Sleep Apnea (OSA)	Not Unfitting	OSA	6847	50%	20070822	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Bilateral Knee Pain, Status Post [S/P] Multiple Surgeries each Knee. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had multiple pre-service surgeries including a left knee anterior cruciate ligament (ACL) repair in 1993, a left ACL revision in 1997, and right arthroscopic surgeries in 1994 and 1996. In May 2006, she complained of bilateral knee  pain  for  3  weeks  as  a  result  of  increased  physical  training.  A  note  dated  21 November 2006 indicated the CI failed rehabilitation and nonsteroidal anti-inflammatory drugs were ineffective. At an orthopedic clinic visit on 16 March 2007, examination revealed the right knee with healed portal scars and range of motion (ROM) 0-140 degrees (normal) with guarding. There was no instability, but there was tenderness of the anterior knee and patella (kneecap). The left knee had a healed surgical scar and portal sites and was stable with a ROM of 0-140 degrees with guarding. Right knee X-rays that same day showed mild DJD, and left knee

X-rays showed mild to moderate degenerative arthritic changes in the knee joint with evidence of previous surgery. The CI was not a surgical candidate for any further intervention for her knees.

The 25 April 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of aching knees all the time with an intensity of 7-8/10. They swelled intermittently, and she could not run. Going up and down stairs caused a great deal of pain. Squatting, prolonged walking, or walking over uneven terrain all greatly aggravated the knee pain. Physical examination showed bilateral joint line tenderness. There was mild patellar tenderness and a negative Lachman's test (to determine instability). Meniscal signs were negative. Extension in both knees was 0 degrees and neither knee was limited by pain. Left knee flexion was 120 degrees, limited by pain, and right knee flexion was 130 and not limited by pain. During the 16 May 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, physical examination revealed slightly decreased bilateral knee flexion.

At the 22 August 2008 VA Compensation and Pension (C&P) examination, 10 months after separation, the CI reported constant localized pain, aching and sharp in nature with the pain level at 8/10, which was relieved by medication. The pain could be elicited by physical activity. On examination there was a normal gait. Bilaterally there was edema, tenderness and guarding of movement and there was no effusion, weakness, redness, heat, and subluxation. Examination of both knees revealed crepitus (grinding sensation) and there was no genu recurvatum or locking pain. The left and right knee ROMs following repetition were flexion 100 degrees and extension 0 degrees limited by pain. There was no instability, laxity, or evidence of a meniscal tear of either knee. X-rays of the right knee showed mild degenerative changes and the left knee showed postoperative changes with degenerative changes prominently involving the medial compartment.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral knee condition 10%, coded 5003 citing pain involving two or more major joints. The VA rated each knee condition 10%, coded 5010 (traumatic arthritis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.

The panel first considered whether each knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. Duty limitations recommended by the 24 June 2007 Army profile included no ruck marching, wearing of individual body armor, impact exercises, or running maximum distance. Exercises were to be at her own pace/distance. The CI was allowed to walk for the alternate physical fitness test. According to the commander’s statement, the CI had been able to perform duties assigned to her within the limits of her profile, but was unable to perform her military occupational specialty due to her medical condition. The NARSUM implicated both knees, and the MEB listed bilateral knee pain as failing retention standards.

The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the unbundled left and/or right knee condition was reasonably considered separately unfitting. The panel then considered its rating recommendation for the unfitting left knee and unfitting right knee conditions at the time of separation. The panel deliberated whether there was sufficient evidence of painful motion with functional loss to support a 10% rating for either knee (based on §§4.59, 4.40 and 4.45). The NARSUM examination cited pain-limited motion on the left side, but not on the right, while the C&P examination indicated crepitus with pain-limited motion, but did not specify objective evidence of painful motion. The panel consensus was that there was sufficient evidence of painful motion with functional loss to support a 10% rating for the left knee condition, but there was insufficient evidence of the same to support higher than 0% rating for the right knee. The panel considered alternative VASRD knee and analogous codes, but all were less applicable

and/or not advantageous to rating. There was therefore no VASRD §4.71a rating higher than the 10% for both knees combined as adjudicated by the PEB, under any applicable code. After due deliberation, considering all 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.

Contended PEB Condition: OSA. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The OSA was first profiled (P3) on 24 June 2007, while the CI was in the DES process for her knee condition and there was one profile restriction attributable to OSA: “must have access to electricity for CPAP machine.” An MEB addendum dated 21 June 2007 stated that a sleep study had been conducted a month earlier, resulting in a diagnosis of mild, REM-predominant OSA-hypopnea syndrome, and a diagnosis of OSA was added to the NARSUM and the DA Form 3947 as not meeting retention standards. The OSA was not implicated in the commander’s statement, and there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. The PEB indicated that her duty performance as indicated in her officer evaluation report from 8 September 2006 thru 28 February 2007 was excellent. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended obstructive sleep apnea condition, the panel recommends no change from the PEB determination as not unfitting. 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.

ARXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXX:

	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.

A copy of this decision has been provided to the counsel you listed on your application.

Sincerely,