RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201800 SEPARATION DATE: 20030626 BOARD DATE: 20130418 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (11B/Infantryman), medically separated for bilateral knee pain with history of right knee prepatellar septic bursitis, bilateral knee pain and right leg pain. On two occasions the CI was injured while performing training. He did not improve with anti-inflammatory medications and has pain with any activity. The bilateral knee pain with history of right knee prepatellar septic bursitis, bilateral knee pain and right leg pain conditions could not be adequately rehabilitated and did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent UP3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded the three conditions of: right knee pain status post (s/p) debridment of prepatellar septic bursitis; right leg pain secondary to shin splints; and left knee pain secondary to retropatellar pain syndrome for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the bilateral knee pain with history of right knee prepatellar septic bursitis, bilateral knee pain and right leg pain conditions as unfitting, rated as a single condition at 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “Can’t stand or walk for long periods of time. Injury worsened knees severly painful”. 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. The conditions bilateral knee pain with history of right knee prepatellar septic bursitis, bilateral knee pain and right leg pain as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview; and, are addressed below. 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 IPEB – Dated 20030328 VA (2 Mos. Pre & 5 Years Post-Separation) – All Effective Date 20070911 Condition Code Rating Condition Code Rating Exam Bilateral Knee Pain with a History of Right Knee Prepatellar Septic Bursitis with Debridement and Bilateral Knee Pain and Right Leg Pain 5099-5003 10% Patellofemoral Syndrome, Left Knee (claimed as bilateral stress fractures of the knees, shin splints, bilateral stress fracture of the legs, and right leg pain) 5299-5260 10% STR & 20080130 Patellofemoral Syndrome, Right Knee (claimed as bilateral stress fractures of the knees, shin splints, bilateral stress fractures of the legs, and right leg pain) 5299-5260 10% STR & 20080130 .No Additional MEB/PEB Entries. No Other VA Conditions Combined: 10% Combined: 20% ANALYSIS SUMMARY: Bilateral Knee Pain with a History of Right Knee Prepatellar Septic Bursitis with Debridement and Bilateral Knee Pain and Right Leg Pain Condition. The PEB combined the right knee pain s/p debridement of prepatellar septic bursitis; right leg pain secondary to shin splints; and left knee pain secondary to retropatellar pain syndrome conditions under a single disability rating, coded analogously to 5003. Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints; and, IAW DoDI 6040.44, the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. If the members judge that separate ratings are indicated IAW VASRD §4.7 (higher of two evaluations), however; each unbundled condition must be reasonably justified as separately unfitting to remain eligible for rating. When the Board recommends separate ratings in this circumstance, the result may not be lower than the overall combined rating from the PEB. The narrative summary (NARSUM) indicates that after initially injuring his right leg in a fall, the CI began experiencing right leg pain although there was no X-ray evidence of fracture. Shortly thereafter, following a crawling exercise, he developed bilateral knee pain and was found to have right knee prepatellar septic bursitis. Although that condition responded to treatment, bilateral knee pain and right leg pain persisted in spite of treatment with anti-inflammatory medications and profiling (including right leg, right knee and left knee). At the time of the MEB, the CI reported that he had pain with any activity and that it was specifically aggravated by kneeling, squatting or bending. MEB physical exam of the right knee showed a healed scar on the medial aspect of the patella. Range-of-motion (ROM) was “from 0°-120° without pain” (normal 0-140 degrees). There was tenderness to palpation. Strength and neurovascular testing were normal, and there was no instability. Left knee ROM was 0-120 degrees absent any mention concerning painful motion and there was normal strength. Neurovascular testing was normal, and there was no instability. The C&P exam most proximal to date of separation was performed in May 2008, more than 5 years post separation. That exam documented bilateral painful motion with additional findings of knee pathology that the VA rated at 10% for each knee. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined bilateral knee pain with a history of right knee prepatellar septic bursitis, and right leg pain as a single unfitting condition, coded analogously to 5003 and rated 10%. The PEB may have relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes. The Board first considered if the right knee, the left knee and the right leg pain (shin splints), having been de-coupled from the combined PEB adjudication, remained unfitting as established above. Members agreed that the functional limitations in evidence justified the conclusion that the right knee and left knee conditions were each integral to the CI’s inability to perform his MOS; and, accordingly a separate rating for each knee is recommended. There was insufficient evidence that the right leg pain (shin splints) condition was separable from the right knee pain condition and it was considered not separately unfitting or ratable. The only C&P exam in evidence took place more than 5 years post separation. It coded both knees separately as 5299-5260 (limitation of flexion of the knee) and, citing painful motion and functional loss, assigned a rating of 10% to each knee for a total combined rating of 20%. However, since this falls well outside the 12-month window specified in DoDI 6040.44 regarding VA evaluations for Board consideration, and is very remote from separation, little probative value can be assigned to that exam. Both the MEB and VA examiners documented a consistent complaint of pain on use particularly with bending, squatting or kneeling. The MEB exam describes ROM of both knees limited to 120 degrees. The commander’s letter states that the CI is unable to function in his MOS which, as mentioned in the NARSUM, requires “a lot of technical maneuvers to include running, jumping or crawling.” VASRD §4.40 states “a part which becomes painful on use must be regarded as seriously disabled,” and the Board conceded applicability of VASRD §4.59, painful motion. The Board considered the VA choice of coding each knee analogous to 5260, loss of motion in flexion. This coding approach, or analogous use of 5003, would yield a minimal 10% compensable rating for each joint with application of §4.59 (painful motion). The CI had no history of surgery or meniscal injury to support use of disability codes 5258 or 5259 (cartilage, semilunar), and there was no route to additional rating for instability under code 5257. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.40 (functional loss), the Board recommends that the bilateral knee condition be rated for two separate unfitting conditions as follows: right knee and leg pain coded 5299-5262 rated 10% and left knee anterior knee pain secondary to patellofemoral syndrome coded 5299-5003 rated 10%. 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 bilateral knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the contended right leg pain condition, the Board unanimously recommends a determination as not separately unfitting. In the matter of the bilateral knee pain condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee pain secondary to prepatellar septic bursitis coded 5299-5262 rated 10%, and an unfitting left knee pain secondary to retropatellar pain syndrome coded 5299-5003 rated 10%, both 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 his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Right Knee Pain Condition Including Leg Pain 5299-5262 10% Left Knee Pain Condition 5299-5003 10% COMBINED (w/ BLF) 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20121004, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130009534 (PD201201800) 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 20% 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 xxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)