RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01846
BRANCH OF SERVICE:  Army	BOARD DATE:  20141125
SEPARATION DATE:  20041203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve SSG/E-6 (88M/Motor Transport Operator) medically separated for bilateral knee pain.  The condition could not be adequately rehabilitated 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 bilateral knee pain condition characterized as “bilateral knee degenerative joint disease (DJD)” and was forwarded to the Physical Evaluation Board (PEB) in accordance with (IAW) AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “bilateral knee degenerative joint disease” as unfitting, rated at 0%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Bilateral Knee Condition.”

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 bilateral knee condition is addressed below; and, 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 20040922 | VA - (5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Bilateral Knee Pain | 5099-5003 | 0% | Left Knee Degenerative Joint Disease | 5010-5260 | 10% | 20050430
| | | Right Knee Degenerative Joint Disease | 5010-5260 | 10% | 20050430
Other x 4 (Not in Scope) | Other x 3 | 20050503
Combined:  0% | Combined:  30%
Derived from VA Rating Decision (VARD) dated 20050608 (most proximate to date of separation)

ANALYSIS SUMMARY:  The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation.  The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence.  Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Bilateral Knee Pain Condition:  Review of the treatment records reveals that the CI, noted to have instability in the knees prior to enlistment in 1977, first received a permanent waiver for an L3 profile for bilateral knee pain in 1983.  After increased physical activity in preparation for a deployment in 2004, she reported chronic bilateral knee pain (for 25 years), recently aggravated by field training.  On examination, full active range-of-motion (ROM) of both knees was noted, with slight effusion (fluid in the knee joint) bilaterally, with patellar crepitance (grinding sensation with movement) and tenderness to palpation along the medial joint line of the left knee.  She was diagnosed with bilateral patellofemoral pain syndrome.  Orthopedic evaluation (dated 11 months prior to separation) noted retropatellar tenderness (behind the kneecap) and absence of either patellar apprehension (a test for instability) or medial or lateral laxity.  Radiographic imaging (dated ten months prior to separation) noted bilateral slight effusion and degenerative changes in the medical meniscus.

Permanent L3 profile, dated 9 months prior to separation, noted DJD of both knees and recommended no running, jumping, marching, rucking, repetitive bending or squatting, standing longer than an minute, and limited lifting items that weight more than 25 pounds.  The commander’s memorandum to the MEB stated that the CI’s impairments “prevent her from fulfilling the requirements of an 88M.”  At the MEB examination, the CI reported knee pain.  The MEB physical examination noted full knee flexion bilaterally, with hyperextension (increased extension) noted, and absence of ligamentous laxity or instability.  

The narrative summary (NARSUM) documented bilateral knee pain (6/10), worse with standing and frequent exercise. Her condition was diagnosed as retropatellar pain syndrome; however no surgical intervention was indicated.  The NARSUM diagnosis was bilateral knee DJD, frequent and at minimal intensity.  The MEB (3 months prior to separation), forwarded the bilateral knee DJD condition as medically unacceptable to the PEB 10 weeks prior to separation.  The IPEB found the bilateral knee DJD as unfitting, rated as minimal and frequent.

At the VA Compensation and Pension exam (performed 5 months after separation), the CI reported that the knee pain had begun in 1999, exacerbated by hyperextension of her knees.  (The VA also noted diffuse ligamentous laxity in many other joints).  The VA examiner noted full ROM of both knees, without effusion, tenderness, instability and no limitation of motion with repetitive use.  X-rays at the VA were read as “normal.”  The VA noted that the hyperextension of her knees was “an underlying condition,” not “secondary to injuries while in the military.”

The goniometric 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)

PT ~11 Mo. Pre-Sep
(20040121)

MEB ~5 Mo. Pre-Sep
(20040707)

VA C&P ~5 Mo. Post-Sep
(20050430)

| Left | Right | Left | Right | Left | Right
Flexion (140 Normal) | 135 | 135 | 135 | 138 | 140 | 140
Extension (0 Normal)* | -10 | -10 | -20 | -18 | -15 | -15
Comment | + patellar crepitance, + diffuse tenderness, no instability | + patellar crepitance, + diffuse tenderness, no instability | No laxity or instability. | No laxity or instability | +Hyperextension, no instability, tenderness, effusion, or limitation with repetitive use. | +Hyperextension, no instability, tenderness, effusion, or limitation with repetitive use.
§4.59 Rating | 10% | 10% | 10% | 10% | 10% | 10%
*Negative ROM values upon extension denote motion which exceeds full extension, and not a limitation of extension.

The Board directs attention to its rating recommendation based on the above evidence.  The IPEB, noting pain as minimal and frequent, rated the condition at 0% IAW the USAPDA pain policy, noting VARD code 5099-5003.  The VARD (dated 6 months after separation), noting full ROM without pain, absence of tenderness or instability, rated the condition at 10% for each knee, under VASRD code 5010-5260, based upon functional loss due to pain, worse when standing, walking or squatting, with a diagnosis of DJD.

This Board considered alternate coding under the VASRD 5200 code series for knee conditions, none of which were applicable in this case.  The Board noted that the CI’s functional loss with pain, and radiographic evidence of DJD, met the criteria for a 10% rating under VASRD code 5003.  A higher rating of 20% was not indicated, as there was no limitation of flexion or extension which would qualify for a rating under VASRD code 5260.  As there were no documented incapacitating exacerbations, a higher rating under VASRD code 5003 was not indicated as well.

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 each knee DJD 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 DoDI 1332.39 for rating the bilateral knee pain condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the bilateral knee DJD condition, the Board unanimously recommends a disability rating of 10%, for each knee, with bilateral factor (BLF), coded 5003-5260 IAW VASRD §4.59, §4.71a and §4.26 (bilateral factor).  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
Right knee degenerative joint disease (DJD) condition | 5003-5260 | 10%
Left knee degenerative joint disease (DJD) condition | 5003-5260 | 10%
COMBINED (w/ BLF) | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131009, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150006401 (PD201301846)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01846