RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX CASE: PD1201601 BRANCH OF SERVICE: ARMY BOARD DATE: 20130423 SEPARATION DATE: 20030713 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (52C/Utility Equipment Mechanic) medically separated for a bilateral knee condition. She experienced an onset of knee pain in 1998. After undergoing several treatment modalities, the condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent U2/L3/P2 profile and referred for a Medical Evaluation Board (MEB). The knee condition, characterized as bilateral retropatellar pain syndrome was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated chronic knee pain due to bilateral retropatellar pain syndrome as unfitting, rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated. CI CONTENTION: “My rating only focused on my chronic knee pain. The rating did not include my severe decrease in visual acuity, my chronic instability of both ankles, my chronic carpal tunnel in both wrists, or my abdominal pain from my C-section. I also have severe migraines caused my visions issues. I am still suffering with back pain and my weight. The injury to my right breast and cysts caused a deformity in my right breast. This deformity causes great body image issues that I am still struggling with today. I also still have occasional painful ovarian cysts.” [sic] SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation. The rating for the unfitting knee condition is addressed below. The requested eye, ankle, wrist, abdominal pain, migraine, and breast cyst conditions were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030404 VA - (4 Days Pre-Separation) Condition Code Rating Condition Code Rating Exam Chronic Knee Pain Due To Bilateral Retropatellar Pain Syndrome 5099-5003 0% Retropatellar Pain Syndrome, Right Knee 5260 10% 20030414 Retropatellar Pain Syndrome, Left Knee 5260 10% 20030414 No Additional MEB/PEB Entries Other x 8 20030417 Combined: 0% Combined: 60% Derived from VA Rating Decision (VARD) dated 20030709. ANALYSIS SUMMARY: Chronic Knee Pain Condition. The PEB combined the right and left knee conditions as a single unfitting and solely rated condition, coded analogously to 5003. Although this approach complies with AR 635.40 (B.24 f.); the Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are reasonably justified IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must 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. Thus the Board must exercise 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 CI had a history of non-traumatic left knee pain in 1998 which became bilateral knee pain in 2000. Pain was associated with running or jumping. Knee X-rays and a bone scan were completely normal. Serial physical examination findings led to a diagnosis of bilateral retropatellar pain syndrome. Despite long-term profiling, anti-inflammatory medications, aggressive physical therapy (PT), and activity modification, bilateral knee pain persisted. Some service treatment record notes also documented bilateral hypermobile patella, bilateral patellar grinding, crepitus, and apprehension. Clinical notes consistently documented a normal gait. The range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. Knee ROM (Degrees) Ortho ~14 Mo. Pre-Sep NARSUM ~ 5 Mo. Pre-Sep VA C&P ~ 3 Mo. Pre-Sep Left Right Left Right Left Right Flexion (140 Normal) 130 130 “FROM” 100 105 Extension (0 Normal) 0 0 0 5 Comment No instability +Crepitus §4.71a Rating 0% 0% 0-10% 0-10% 0% or 10% 0% or 10% The narrative summary (NARSUM) examiner, 5 months prior to separation, notes the CI having daily pain in her knees. Pain was aggravated by stooping or running despite being compliant with prescribed PT exercises. She described difficulty with sports activities, dancing and biking; and could not stand for more than 20 minutes without experiencing knee pain. The physical examination noted bilateral normal knees with no effusions, ecchymosis, swelling, joint line tenderness, or instability. Grind test was negative. Poor tone and conditioning of quadriceps muscles was present bilaterally. The examiner rated the frequency and severity of the CI’s pain as “occasional” and “minimal” respectively. At the VA Compensation and Pension (C&P) examination performed 3 months prior to separation, the CI reported bilateral knee pain on a regular basis with symptoms initiated by running or carrying heavy loads over a long distance. She complained of difficulty standing for long periods and standing up from a kneeling position. Additionally, the CI reported swelling, redness, aching, and “crackle and pop noises” about each knee. She took non-prescription medication to help reduce her symptoms. The VA examiner specifically stated that her impairment at that time was: “…she can’t run, dance, and can’t get up from a kneeling position.” She lost no time from work due to the condition. The physical examination revealed bilateral slightly positive McMurray’s test (a possible indicator of meniscal damage). There was no evidence of joint effusion, instability, ankylosis, or subluxation. Painful motion was absent. Gait was normal and no assistive device was required. The Board directs attention to its rating recommendation based on the above evidence. The Board first considered if each knee, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above. All members agreed that there was reasonable justification that each knee, as an isolated condition, would have rendered the CI incapable of continued service within her MOS; and, accordingly merits a separate rating. The VA assigned a 10% rating for each knee under the 5260 code (limitation of flexion), presumably with application of §4.40 (functional loss) or §4.59 (painful motion) since limitation of flexion noted on the VA exam was non-compensable. The Board agreed that there was no compensable limitation of motion on any exam; and that there was no radiographic evidence of degenerative changes, and no painful motion supporting application of §4.59. The Board debated whether a normal gait and generally unremarkable physical examination findings depicted a sufficiently severe objective functional impairment to warrant application of §4.40 or §4.59. The Board also carefully considered the option of rating both lower extremities together. A bilateral rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability in this case. Since rating analogously defaults to 5003 rating criteria without regard to confirmed radiographic findings, a 10% rating for two major joints is supported. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral lower extremity condition, coded 5099-5003. 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. As discussed above, PEB reliance on the USAPDA pain policy for rating chronic knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic knee pain due to bilateral retropatellar pain syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Bilateral Retropatellar Pain Syndrome 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120701, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxx, AR20130011070 (PD201201601) 1. 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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)