RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201073 SEPARATION DATE: 20021106 BOARD DATE: 20130301 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Soldier, SGT/E-5(63B/Light Wheeled Mechanic), medically separated for bilateral knee pain secondary to retropatellar pain syndrome (RPPS). The CI injured his right knee when he struck a bedframe in June 1997. The CI did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile (right knee only) and referred for a Medical Evaluation Board (MEB). The MEB adjudicated the bilateral knees, RPPS condition as medically unacceptable IAW AR 40-501. Intermittent low back pain (LBP) and intermittently elevated blood pressure (BP), identified in the rating chart below, were determined to meet retention standards. All were forwarded by the MEB to the Physical Evaluation Board (PEB). The PEB adjudicated bilateral knee pain secondary to RPPS as unfitting, rated 0%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD), and adjudicated the other two MEB conditions as not unfitting. The CI made no appeals, and was medically separated with a 0% disability rating. CI CONTENTION: The CI elaborated no specific contention in his application. SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44 Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20021002 VA (7 Days Post-Separation) – All Effective Date 20021107 Condition Code Rating Condition Code Rating Exam Bilateral Knee Pain 5099-5003 0% L Knee RPPS 5299-5260 10% 20021113 R Knee RPPS 5299-5260 10% 20021113 Intermittent LBP Not Unfitting Lumbosacral Strain 5295 10% 20021113 Intermittently Elevated BP Not Unfitting Hypertension 7101 NSC 20021113 .No Additional MEB/PEB Entries. Tinnitus 6260 10% 20021113 R Elbow Tendinitis 5206-5024 10% 20021113 Residuals, Cervical Strain 5290 10% 20021113 Residuals, R Wrist Injury… 5215-5024 10% 20021113 0% X 2 / Not Service-Connected x 2 20021113 Combined: 0% Combined: 50%* *Includes bilateral factor of 1.9%. ANALYSIS SUMMARY: The PEB combined the right and left knee RPPS, under a single code analogous to 5003 (degenerative arthritis) and rated zero percent. IAW VASRD §4.71a, the Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved. As elaborated below; separate compensable ratings for each condition are well supported by the evidence in this case. Having determined that separate ratings are warranted, however, the Board must also satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. Not uncommonly, this approach by the PEB reflects its judgment that the constellation of conditions was unfitting and that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting. The Board therefore exercises the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB. The Board’s threshold for countering Disability Evaluation System fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the same DoDI 6040.44 standards referenced above. In this case, the right and left knee RPPS were well supported as unfitting by evidence from the narrative summary (NARSUM) and service treatment record (STR). As to the judgment as to whether each condition was independently unfitting, the commander’s statement specifically identified and implicated the right knee, and the profile identified the right knee retropatellar pain syndrome condition as a permanent L3. The NARSUM identified bilateral retropatellar knee pain, and the STR supports that description. The permanent L3 profile limited the CI to no lifting up to 30 pounds or wearing a backpack 40 pounds, no KP/mopping/ mowing grass, or marching, nor running, no bicycling, no swimming, no walk or running in pool, with additional physical fitness testing limitations of no two mile run, swim, or bicycle. Separating the impairment related to the right or left knee requires undue speculation; and, there is clinical evidence of significant and similar functional impairment referable to each joint. After deliberation, all members agreed that (more likely than not) each of the conditions, in isolation, would have rendered the CI incapable of continued service within his MOS; and, accordingly each merits a separate disability rating. Bilateral Knee Pain: In reviewing the clinical record, the CI had an injury in 1997 to the right knee after hitting it on the corner of a bed, and then evaluated again that year for right knee pain while sitting, side straddling, and hops, not by running. He was next evaluated for bilateral knee pain, 8 months in duration, in 1998; a bone scan showed moderate stress changes (no report), but bilateral knee X-rays were normal. He was evaluated on 23 July 1998 by orthopedics and diagnosed with RPPS, left greater than right. On 5 June 2001, he was seen for bilateral knee pain for a year, right was more painful, no history of trauma this time. The narrative summary (NARSUM), 4 months prior to separation, noted the CI had received physical therapy without improvement. The condition improved, but flared up in October 1999 and again in June 2001. He was re-evaluated by orthopedics, and again diagnosed with RPPS. He followed up with orthopedics in June 2002; he again reported no improvement. The CI reported he could walk up to one and a half miles. The NARSUM stated limitations were no running, squatting, kneeling, or crawling. He used Acetaminophen for pain as needed. His commander’s statement confirmed he can no longer perform his MOS duties. The CI was limited by his permanent L3 profile form running, jumping, squatting, rucksack, marching and lifting more than 30 pounds. He could walk at own pace and distance for aerobic conditioning and walk as alternate aerobic event for Army physical fitness test. The accession profile and physical demands rating for the MOS of 63B are 222222 and very heavy. There were two goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Knee ROM MEB ~4 Mo. Pre-Sep VA C&P ~7 Days Post-Sep Left Right Left Right Flexion (140° Normal) 140 140 140 140 Extension (0° Normal) 0 0 0 0 Comment Normal; Silent to painful motion Normal; Silent to painful motion RPPS; Silent to painful motion; No DeLuca RPPS; Silent to painful motion; No DeLuca §4.71a Rating 0% 0% 0% 0% At the VA Compensation and Pension (C&P) exam, 7 days after separation, the CI reported pain behind the kneecaps, increased by sitting to standing, squatting to standing, kneeling to standing, stairs, and that sometimes the knees seemed to give out. He reported flare-ups one to five times a month depending on activities. Physical examination was positive for RPPS, right more than left, with patellar pressure of 5 pounds applied. The knees had a normal appearance and motion; DeLuca criteria were negative upon performing squatting to standing and kneeling to standing testing, which were limitations stated on the NARSUM. The VA examiner speculated that there could be an additional five and ten degree loss in flexion for the right and left knee, respectively, in a flare-up. The action officer opined that the speculation on the part of the VA medical examiner as to the effects of pain from RPPS upon ROM was not supported by the evidence. The Board found no radiological or clinical evidence of pathology which would cause any temporary limitation of motion of the knee, such as a loose body in the knee joint, torn ligaments, severe inflammation, tendinitis, bursitis, osteoarthritis, or documented ROM measurements during an exacerbation. The Board concluded that a hypothesized limitation of motion during an exacerbation that could not be provoked by kneeling or squatting in the examination room could not be considered for a permanent disability rating by the Board. The Board directs attention to its rating recommendation based on the above evidence. The Board considered the VASRD diagnostic code 5099-5003 (rated analogous to arthritis) for both knees, used by the PEB for a zero percent adjudication. The board did not find any evidence of painful motion, or any abnormal x-rays for a rating in the CI’s favor for either the right or the left knee. The Board then considered 5299-5260 (rated analogous to limitation of flexion of leg). The Board found no evidence of flexion limited to 60 degrees or more for a compensable rating above zero percent for each knee. The Board also considered 5257 knee, other impairment, and found no evidence of recurrent subluxation or lateral instability of either knee, for a rating in the CI’s favor. The Board concluded that separating the bilateral knee condition into right and left knee conditions gave no rating advantage to the CI. The Board noted that while the VA based its adjudication of 10% disability for each knee based on the speculation by the C&P examiner that there would be some limitation in motion with a flare, none was in evidence at the examination including repetition of motion and provocative maneuvers. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral retropatellar pain. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Bilateral Knee Pain Condition 5099-5003 0% COMBINED 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120613, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxx, AR20130005379 (PD201201073) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)