RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05422
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041020 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Finance Specialist, medically separated for “bilateral knee pain secondary to chondromalacia” with a disability rating of 10%.   

CI CONTENTION:  Review requested of knee, back and foot conditions as well as 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 – 20040928 	VARD -20050913	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain…	5003	10%	Patellofemoral Pain Syndrome. Right Knee	5099-5020	0%	20050414	
			Patellofemoral Pain Syndrome. Left Knee	5099-5020	0%	20050414	
Low Back Pain 	Not Unfitting	Thoracolumbar Degenerative Disc Disease and Degenerative Joint Disease 	5242	10%	20050414	
Right Plantar Fasciitis	Not Unfitting	Residual, Right Foot Injury	5284	NSC	20050414	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5003 (arthritis, degenerative) and rated 10%.  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 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 adjudicated by the PEB.  The evidence for the right and left knee conditions are presented separately, 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 had a several year history of bilateral knee pain, right greater than left.  Since entry onto active status in January 2003, the pain became progressively worse, and X-rays revealed mild degenerative changes, with no evidence of fracture.  The 13 July 2004 profile noted duty limitations for the right knee only and included no running, rucking, marching, or high impact activities like jumping.  

The 10 August 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, revealed a normal lower extremity evaluation except for decreased range of motion (ROM).  The 24 August 2004 MEB NARSUM noted constant retropatellar pain, rated at 5/10, and increased to 10/10 when aggravated by walking, running, crawling, and prolonged standing or sitting.  The CI reported recurrent knee swelling, popping, and giving way.  Physical examination of the right knee revealed patellar grind but no deformity or effusion;   ROM was from 0-130 degrees (normal 0-140), with pain at the extremes.  The left knee had palpable patellar crepitus, but no deformity or effusion, and  ROM from 0-130 degrees, with pain at the end point of flexion.  

At the 14 April 2005 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI complained of daily flare-ups, with intermittent sharp pain that was severe in intensity particularly at the end of the day.  Pain was precipitated by prolonged standing or bending, as well as lifting heavy objects.  He reported right knee locking following prolonged sitting and when trying to get up daily, but denied left knee locking.  The right knee gave way laterally every day, while the left knee gave way laterally once a week while walking.  Right knee examination showed mild patellar tenderness, but no swelling, erythema, or crepitus.  Flexion was from 0-135 degrees, with pain starting at 120 degrees and ending at 100 degrees, and no limitation with repetition.  The left knee also showed mild patellar tenderness and no swelling, erythema, or crepitus.  Flexion was from 0-135 degrees, with mild pain elicited at 135 degrees, and no limitation of motion noted with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5003 (arthritis, degenerative).  The VA rated the left and right knee conditions 0% each, coded analogously to 5020 (synovitis), citing no objective evidence of painful or limited motion of a major joint or group of minor joints.  Members first considered whether either knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  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 military specialty performance, members agreed that each knee was reasonably justified as separately unfitting.  

Although there was insufficient limitation of flexion or extension to support ratings under code 5260 or 5261, the panel agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) for the right knee as evidenced on the NARSUM examination.  The panel noted evidence of pain at the end ranges of left knee flexion on the NARSUM examination, however treatment notes and the VA examination did not support functional loss as a result of pain at the extremes for motion, and met criteria for no higher than a 0% rating.  The combined rating did not result in a rating higher than that adjudicated by the PEB, and thus provided no benefit to the CI.  After due deliberation, considering all of the evidence, the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

Contended PEB Conditions:  Low Back Pain and Right Plantar Fasciitis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended low back pain and right plantar fasciitis, the panel recommends no change from the PEB determinations 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. 

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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.