RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:	BRANCH OF SERVICE:  Army
CASE NUMBER:  PD1200589	SEPARATION DATE:  20021115
BOARD DATE:  20130503

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4, (75H/Personnel Records Specialist), medically separated for bilateral knee pain.  The CI had bilateral knee pain since 1998 that worsened after physical activities.  The bilateral knee pain did not improve adequately with treatment to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication.  The PEB adjudicated the bilateral knee condition(s) as a single unfitting condition and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I was never given a rating for my knees.”

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 conditions “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 IPEB – Dated 20020912	VA (6 Mos. Post-Separation) – All Effective Date 20021116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Left Knee	5299-5262	0%	20030509	
			Right Knee	5299-5262	0%	20030509	
↓No Additional MEB/PEB Entries↓	0% X 2 / Not Service-Connected x 1		
Combined:  0%	Combined:  0%	

ANALYSIS SUMMARY:

Bilateral Knee Pain.  The PEB combined the right and left knee pain conditions as a single unfitting condition coded analogously to 5003 and rated 0% with application of the USAPDA pain policy AR 635-40 B24.f.  The 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 or implied adjudication that each condition was separately unfitting.  The Board also noted that “bundling,” the combining of two or more major joints is permissible under the Veterans Affairs Schedule for Rating Disabilities (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 Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board 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 Disability Evaluation System or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

The Board considered whether each knee pain condition, when considered alone separate from the other, was unfitting for continued military service.  Service treatment records documented care for pain occurring in both knees since onset in 1998.  There was no specific injury or trauma.  Orthopedic evaluations rendered non-specific diagnosis of bilateral knee pain based on generally normal examination findings with occasional findings of peri-patellar tenderness and crepitus.  Developmental characteristics of genu valgus with coxa vara resulting in a knock knee position and a toe in gait were noted.  She was treated with medications and physical therapy but continued to have knee pain that was worsened after physical activities to include increasing pain and swelling.  The CI was unable ruck, to run at her own pace or distance, and was unable to cycle.  The symptoms increased with prolonged sitting, walking and squat exercises.  Examinations at the time of the MEB indicated the left knee to be somewhat worse than the right however there was not a preponderance of evidence to indicate that either right or left knee when considered alone was not unfitting for continued military service.  Therefore the Board next considered the ratings for the unfitting right and left knee pain conditions.  The MEB narrative summary (NARSUM) examination 1 July 2002, 4 months prior to separation, noted full range-of-motion (ROM) of both knees (flexion 125 degrees, extension zero degrees; similar to prior orthopedic examinations in October 1999 and January 2002).  There was slight inward facing of the patella and slight “knock kneed” deformity.  There was an absence of effusion, point tenderness, and no ligamentous laxity or instability.  There was a positive inhibition test on the left more than the right (for patellar pain syndrome).  X-rays were normal with the exception of a noncontributory finding of a small exostosis on the left tibia.  There was no abnormality for which surgical treatment was recommended.  At the VA Compensation and Pension (C&P) examination on 9 May 2003 (6 months after separation) the CI reported occasional pain and weakness in the knees but no instability, locking, fatigue or lack of endurance.  Pain occurred with prolonged standing about once per month and was improved with rest.  She was able to work without difficulty; the examiner noted the CI “….works at QFC and she chops seafood and she is able to move back and forth and she usually does not have a problem with her knees at work.”  On physical examination, the examiner found no swelling, deformity and a normal ROM in both knees (flexion 140 degrees, extension 0 degrees).  There was no pain, instability, and strength and ligaments were normal.  When palpating the patella, the CI identified that the medial border of the patella was the location of the pain when it occurred.  The patellar compression test (for patellar pain syndrome) was negative.  X-rays also showed the aforementioned exostosis but were otherwise normal.

The Board directs attention to its rating recommendation based on the above evidence.  There was not any limitation of motion that attained a minimum rating under the VASRD codes for limitation of motion (6260, 5261).  The MEB NARSUM ROM testing showed near normal flexion and normal extension and the C&P examination proximate to separation demonstrated completely normal flexion and extension.  There was no instability to warrant a minimum rating under 5257 and there was no meniscus pathology or meniscus surgery to warrant consideration under 5258 or 5259.  There was no degenerative arthritis to support a minimum rating under 5003 for bilateral knee degenerative arthritis.  The Board also considered the provisions of §4.59 (painful motion) and §4.40 (functional loss).  The CI had knee pain that prevented strenuous military activities, however there was no impairment in her post separation employment that involved moving about.  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 knee pain condition.

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 the bilateral knee pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the bilateral knee pain 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 	5099-5003	0%	
COMBINED	0%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB),

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130010958 (PD201200589)

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA