RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00367
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150716
SEPARATION DATE:  20070831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Military Policeman) medically separated for bilateral knee pain.  His knees could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Bilateral retropatellar pain syndrome and patellar chondromalacia were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated his bilateral knee pain as unfitting, rated 10% with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The findings and rating were forwarded to the USAPDA for approval.  The USAPDA approved the findings and rating, but made a minor administrative correction.  The CI made no appeals and was medically separated.

CI CONTENTION:  The applicant makes no specific contention in his application.  He stated not all service related conditions were evaluated.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any condition outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

Admin PEB – Dated 20070727	VA* - (1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain…	5099-5003	10%	Left Knee Chondromalacia Patella…	5099-5014	10%	20070808	
			Chondromalacia Patella with Degenerative Changes, Right Knee	5003-5260	10%	20070808	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080124 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The PEB combined the left and right knee pain 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 Service 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.

Bilateral Knee Condition.  At an initial orthopedic evaluation in January 2007 (7 months prior to separation) the CI reported a history of atraumatic right greater than left knee pain.  Right knee pain worsened after an impact injury from an IED explosion in June 2006, but evaluation at that time showed no structural damage.  He complained of bilateral knee swelling, buckling, stiffness and locking.  Examination showed a normal gait, no visible swelling, and bilateral knee tenderness.  Bilateral knee range-of-motion (ROM) was normal (but unmeasured) and all ligaments were stable.  One sign of possible meniscal injury was positive on the right.  Subsequent magnetic resonance imaging (MRI) of the right knee was normal, but a medial meniscal tear could not be definitively excluded.  Left knee X-rays were normal.

At follow-up on 7 March 2007 (6 months prior to separation), the CI reported occasional feelings of locking and giving way.  Current pain in the right knee was 3/10 in severity.  Examination showed right knee tenderness and painful patellar compression, and the left knee displayed painful patellar compression.  ROM in both knees was reported to be “full” and all ligaments were stable.  The orthopedist’s opinion was that the right knee MRI was normal.

On the DD Form 2808, Report of Medical Examination, dated 29 March 2007, the CI reported use of a right knee brace.  Exam showed pain in both knees during deep knee bending.  At the MEB narrative summary (NARSUM) evaluation on 30 May 2007 (3 months prior to separation), the CI’s chief complaint was right greater than left knee pain which had not responded to extensive physical therapy (PT), profiling or medication.  Extended walking was difficult and he could not run due to knee pain.  Examination was unchanged from the 7 March 2007 exam, and diagnoses of bilateral retropatellar pain syndrome and patellar chondromalacia were rendered.

At the VA Compensation and Pension (C&P) exam performed a month before separation, the CI reported flare-ups of right knee pain 3 times per week and occasional use of a right knee brace.  Bilateral knee pain caused sleep disturbance and pain with bending, kneeling or climbing.  Examination showed a normal gait without use of assistive devices.  Deep knee bending caused pain in both knees.  Crepitus and tenderness were present in the right knee but not the left.

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 ~6 Mos. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	135, 135, 135	102, 105, 105	120	105	
Extension (0 Normal)	0	0	0	0	
Comment	ROM limited by pain	Painful motion at extremes of motion	
§4.71a Rating	0% or 10%	0% or 10%	0% or 10% (VA 10%)	0% or 10% (VA 10%)	

The Board directed its attention to its rating recommendation based on the above evidence.  The Board first considered whether the right and left knee conditions, when considered independently, were separately unfitting for continued military service and therefore warranted separate ratings.  Although knee pain was worse in the right than the left, the record showed consistent complaints of bilateral knee pain, and each knee was reported to interfere with functional activities.  The NARSUM identified bilateral knee disease as medically unacceptable, and both knees were identified on the permanent profile.  The Board unanimously agreed therefore, that the right and left knee conditions were reasonably justified as separately unfitting and that they met VASRD §4.71a criteria for separate ratings.  The VA assigned a 10% rating for each knee based on evidence of limitation of motion due to pain.  Board members agreed there was no evidence of compensable limitation of motion, but concluded that there was sufficient evidence of painful motion to warrant a 10% rating for each knee IAW VASRD §4.59.  There was no evidence of knee ankylosis, dislocated meniscus, or instability for rating consideration under the corresponding diagnostic codes (5256, 5258, and 5257 respectively).  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 right knee pain condition and 10% for the left knee pain 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 knee pain was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the bilateral knee pain condition, the Board recommends that it be rated for two separate unfitting conditions as follows:  chronic right knee pain condition coded 5099-5003 and rated 10%; and chronic left knee pain condition coded 5099-5003 and 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:

CONDITION	VASRD CODE	RATING	
Right Knee Pain	5099-5003	10%	
Left Knee Pain	5099-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140110, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD 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, AR20150013679 (PD201400367)

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