RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01828
BRANCH OF SERVICE:  Army	BOARD DATE:  20140604
SEPARATION DATE:  20050801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (91X/Mental Health Specialist) medically separated for bilateral knee pain.  The CI developed knee pain while serving in Korea during her running regimen.  The knee condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 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.  The MEB also identified and forwarded one other condition.  The Informal PEB adjudicated “bilateral knee pain secondary to retropatellar pain syndrome” as unfitting, rated 0% with application of the VA Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I suffer daily from chronic joint pain that was found to be service-connected. Prior to dealing with these medical issues, I had planned of serving 20 years in the Army.  The untimely end to my military service was a direct result of these medical issues, which limit work and activities.  Unfortunately, there is no surgery that will help my condition.  I feel that the rating awarded by the Army was not appropriate for my injuries.”

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.  The rating for the unfitting knee condition is addressed below; no additional conditions are 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 20050509 | VA - (5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Bilateral Knee Pain Secondary to Retropatellar Pain Syndrome | 5099-5003 | 0% | Chondromalacia, L Knee | 5299-5260 | 10% | 20060119
| | | Chondromalacia, R Knee | 5299-5260 | 10%* | 20060119
Other X 1 (Not in Scope) | Other x 5 | 20060119
Combined:  0% | Combined:  30%
Derived from VA Rating Decision (VARD) dated 20060424 (most proximate to date of separation [DOS]).  *The initial VARD summary error of 0% was corrected on VARD dated 20060608 using the same evidence and rating narrative.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Bilateral Knee Pain Secondary to Retropatellar Pain Syndrome.  Records from the CI’s service treatment were reviewed which indicated her knees “began giving out during running” when on duty in Korea in 2002.  She had been a cross country runner in high school without a history of knee problems, but did have a “fractured bone” of the left foot in 1999.  Climbing stairs became difficult and painful.  A 14 February 2002 note addressed a 4-month history of right anterior knee pain diagnosed as Osgood-Schlatter syndrome (inflammation of the upper portion tibia).  Evaluation, raising the possible diagnosis of Sinding-Larsen-Johansson disease (pain as a result of excessive force exerted by the patellar tendon on the lower pole of the kneecap) and treatment by physical therapy, orthopedics and podiatry including the use of boot inserts and nonsteroidal anti-inflammatory medication failed to mitigate the knee pain bilaterally, which at times the right was noted to be greater than left.  A bone scan dated 1 July 2003 showed moderate to intense uptake consistent with overuse syndrome of both legs while X-rays in September 2004 were normal.  At the MEB exam, the CI reported “continuous knee pain, both knees, throbbing by 1600 . . . [and] wore right and left knee braces . . . when on feet all day long. . .”  The MEB physical exam dated 5 November 2004 noted retropetallar [behind the knee cap] pain and ligamentous laxity.  The commander’s statement noted the CI experienced pain on a daily basis, had a permanent L3 profile not permitting her to run, jump, backpack march, perform flutter kicks, wear a helmet, carry or fire a rifle or lift anything.  She was allowed to walk and bicycle at her own pace.  He stated she “wears knee braces; however, they do not prevent her knees from locking up.”  The MEB NARSUM dated 12 January 2005 noted constant throbbing behind both knee caps at a pain level of 4/10 that worsened with walking, stair climbing, running, bicycling or jumping.  The knees rubbed and popped with walking and when more than 20 pounds was carried.  The NARSUM author noted examination of the knees showed full range-of-motion (ROM) bilaterally and referred to a 30 September 2004 orthopedic examination that revealed gross valgus (twisted outward) deformity of 20 degrees; the Q angle, which measured 30 degrees bilaterally (N=17 degrees +/- 3 degrees) and systemic ligamentous laxity in all of her joints, including recurvatum (backward bending) of the knees and hyperextensibility of the digits and thumb.  There was pain with the patellar grind; patellar tilt was not grossly excessive; and there was a positive apprehension test bilaterally with laterally directed patellar stress.  A more pronounced anterior tibial tubercle on the right than on the left was suggestive of old Osgood-Schlatter disease.  No surgery was recommended.  She was unable to carry litter patients, set up tents or equipment, run, jump or bicycle and limped when walking for long distances.  No improvement was noted over 2 years.

At the VA Compensation and Pension exam performed 5 months after separation, the CI reported no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement bilaterally.  The right knee clicked and both the right and left knees hyperextended.  The stability tests of the ligaments and meniscal tests were normal for each knee.

The Board directs attention to its rating recommendation based on the above evidence.  The Informal PEB found the CI unfit for bilateral knee pain secondary to retropatellar pain syndrome and using the VA code 5099-5003 rated the CI 0% whereas the VA rated the CI’s conditions using code 5299-5260 for chondromalacia of the left knee at 10% by relying on a ROM for flexion of 112 degrees (normal 140 degrees) limited by pain, fatigue and lack of endurance and code 5299-5260 for chondromalacia for the right knee initially at 10% relying on a ROM of 110 degrees limited by pain, fatigue and lack of endurance.  The PEB combined the left and right knee 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.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  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.  The Board first considered if each knee having been de-coupled from the opposite knee, remained itself unfitting as established above.  Both knees had similar exams and similar history, with most records of treatment for bilateral knees.  Bilateral knees were profiled and mentioned in the commander’s comments.  Members agreed that the functional limitations in evidence justified the conclusion that each knee was reasonably unfitting and, accordingly a separate rating is recommended for each knee.  The NARSUM findings of patellar apprehension and patellar grind were consistent with the remainder of the record.  The treatment notes, history and specific diagnosis of “retropatellar pain syndrome” support painful motion for each knee.  The NARSUM and service record did not specify repetitive motion testing or DeLuca factors, while the VA exam specified DeLuca criteria, painful motion as well as pain-limited motion.  Taking into account §4.59 (painful motion) each knee warrants a 10% rating.  Additionally, consideration of code 5299-5263 Genu recurvatum (knee bends backward) was considered as alternative coding for each knee due to the Q angle; however, there was no indication of trauma, or that it was an acquired condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.40 (functional loss), the Board recommends a disability rating of 10% for the left knee pain secondary to retropatellar pain syndrome condition and a 10% rating for the right knee pain secondary to retropatellar pain syndrome 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.  In the matter of the bilateral knee pain secondary to retropatellar pain syndrome the Board unanimously recommends that the left knee and right knee each be considered unfitting and each knee rated separately at 10% coded 5009-5003 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
Left Knee Pain Secondary to Retropatellar Pain Syndrome | 5099-5003 | 10%
Right Knee Pain Secondary to Retropatellar Pain Syndrome | 5099-5003 | 10%
COMBINED (w/BLF) | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131021, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB			

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150001223 (PD201301828)

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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01828