RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00548
BRANCH OF SERVICE:  Army	BOARD DATE:  20141017
SEPARATION DATE:  20070713

SUMMARY OF CASE:  The evidence of record indicates that this covered individual (CI) was an activated Reserve PFC/E-3 (88M/Motor Transport Operator) medically separated for left knee and ankle pain.  Her condition did not improve adequately to meet the 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).  Four left lower extremity (LLE) conditions, “left tibial stress fracture,” “left knee sprain,” “left ankle sprain” and “left patellofemoral syndrome” (with the fourth listed as medically acceptable), were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic left knee and ankle pain” as unfitting, rated 10%, referencing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The left patellofemoral syndrome was found to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Due to the increase of my conditions and mistreatment.”

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 LLE conditions are addressed below.  No other conditions are within the defined purview of the Board.  Any conditions outside the Board’s scope of review may be eligible for consideration by the Board for Correction of Military Records.  

RATING COMPARISON:

Service PEB – Dated 20070622	VA – (9 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee & Ankle Pain	5099-5003	10%	Left Knee Patellofemoral Pain Syndrome	5260	10%	20080415	
Left Patellofemoral Sydrome	Not Unfitting					
Other x 0	Other x 5	
Rating:  10%	Rating:  10%	
Derived from VA Rating Decision (VARD) dated 20080813

ANALYSIS SUMMARY:  The Board acknowledges the CI’s contention that her conditions have increased.  It is noted for the record that the Board is subject to the same laws for disability entitlements as those under which the Disability Evaluation System (DES) operates.  The DES has neither the role nor the authority to compensate members for future severity of conditions.  That role and authority is granted to the Department of Veterans Affairs.  The Board evaluates VA evidence in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness and rating determinations at the time of separation.

The Board also acknowledges the CI’s contention of mistreatment.  It must be noted for the record that the Board has neither the jurisdiction nor authority to scrutinize or render opinions in regard to this matter. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of DES fitness and rating determinations, based on severity at separation.

Chronic Left Knee and Ankle Pain.  In February 2007, the CI started having pain in her left knee.  Bone scan showed moderate intense activity at the left tibial plateau.  She was treated with medication and rest.  However, the knee pain persisted.  In April 2007, she was seen by orthopedics.  There was diffuse tenderness of the left knee, especially over the medial patella and patellar ligament.  Tests for ligamentous laxity were negative.  Active range-of-motion (ROM) of the left knee was full, with pain.  Based on physical exam and radiological findings, the CI was diagnosed with stress fracture of the left medial tibial plateau.  The examiner opined that the CI was unlikely to complete physical training without an extended period of rest, followed by gradual re-conditioning.  The examiner recommended a MEB be initiated.  The MEB physical examination (PE) was in May 2007.  There was moderate tenderness to palpation at the proximal medial tibia, but no swelling.  Lachman’s test was negative.  There was pain with McMurray’s test.  Knee ROM was measured and is summarized in the chart below.

The CI separated from service on 13 July 2007.  Nine months later, she had a VA Compensation and Pension (C&P) exam.  At that time, she was able to stand for 15-30 minutes.  She was able to walk more than a quarter mile, but less than one mile.  Her gait was antalgic.  Examination of the left knee revealed painful movement and guarding of movement.  There was some subpatellar tenderness; but no crepitation, clicks, snaps, grinding, instability, or other joint abnormality.  The C&P examiner wrote, “Exam of the left knee is severely limited due to exaggerated pain.  Any slight movement or light touch elicits a severe pain response from the patient.”  The left knee ROM evaluations which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Left Knee ROM
(Degrees)	Ortho ~ 3 Mos. Pre-Sep
	MEB ~ 2 Mos. Pre-Sep
	VA C&P ~ 9 Mos. Post-Sep
	
Flexion (140 Normal)	AROM “full with pain”	80	40	
Extension (0 Normal)	AROM “full with pain”	15	0	

In December 2006 the CI injured her left ankle.  She was treated and her symptoms improved slightly.  However, the ankle pain did not go away.  At the April 2007 orthopedic visit, there was full ROM of the left ankle and foot.  The examiner’s diagnosis was ankle sprain.  At the MEB physical examination (PE) in May 2007, there was some tenderness of the medial malleolus, posterior greater than anterior.  Ankle ROM was measured and is summarized in the chart below.  At the April 2008 C&P exam, her ankle was much better.  Left ankle ROM was much improved.  The examiner wrote, “Normal left ankle.”  The left ankle ROM evaluations which the Board weighed in arriving at its recommendation are shown in the chart below.

Left Ankle ROM
(Degrees)	Ortho ~ 3 Mos. Pre-Sep
	MEB ~ 2 Mos. Pre-Sep
	VA C&P ~ 9 Mos. Post-Sep
	
Dorsiflexion (20 Normal)	AROM “full”	10	20	
Plantar Flexion (45)	AROM “full”	18	40	

The Board carefully reviewed all available evidence and directs attention to its rating recommendation.  The PEB chose diagnostic code 5099-5003 (analogous to degenerative arthritis), and assigned a disability rating of 10% with application of the USAPDA pain policy.  The knee pain and the ankle pain were bundled and treated as a single unfitting condition.  The Board evaluated whether or not it was appropriate for the two painful joints to be “bundled.”  The Board must determine if the PEB’s approach of combining the problems under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendations if compensable ratings for each condition are achieved IAW the VA Schedule for Rating Disabilities (VASRD).  If the Board judges that two or more separate ratings are warranted, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting.  After due deliberation, the Board determined that the evidence did not support a conclusion that each of the chronic pain problems, separately, would have rendered the CI unable to perform her required military duties.  Specifically, the Board did not find sufficient evidence that the left ankle pain was separately unfitting.  Therefore, by majority decision the Board does not recommend a separate disability rating.  

The Board reviewed all the data from the physical exams noted above.  The April 2008 C&P exam was 9 months after separation and therefore had diminished probative value.  The May 2007 MEB exam performed 2 months prior to separation.  However, there were certain inconsistencies with the PE, which caused the Board members to question its validity and probative value.  At that exam, left knee flexion was 80 degrees and improved to 82 degrees with repetitive motion.  Extension was 15 degrees and improved to 12 degrees with repetitive motion.  The examiner wrote, “limitation of motion due to pain.”  The Board found it unlikely that these ROM measurements were valid.  Left knee ROM had been “full, with pain” just one month prior.  The Board suspected that the May 2007 MEB examiner had recorded the point at which pain began, instead of recording true ROM values.  The 5 April 2007 examination was performed by an orthopedic doctor at Wilford Hall Medical Center in San Antonio, Texas.  The Board members determined that of the three exams in question, the April 2007 exam had greatest probative value.  At that exam, there was diffuse tenderness of the left knee, especially over the medial patella and patellar ligament.  Tests for ligamentous laxity were negative.  Left knee ROM was full and left ankle ROM was full.

The CI’s painful LLE condition was essentially non-compensable based on the VASRD §4.71a diagnostic codes for the knee and leg (5256 through 5263) and the ankle (5270 through 5274).  However; IAW VASRD §4.40, §4.45, and §4.59, when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional limitation due to painful motion.  There was no path to a higher rating for the LLE condition since there was no evidence of a significantly disabling abnormality which would justify a higher rating.  Based on a thorough review of the evidence in the treatment record, the Board determined that, at the time of separation a rating of 10% was appropriate.  After due deliberation, considering all of the evidence, and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient reason to recommend a change in the PEB adjudication of the LLE condition (Chronic left knee and ankle pain).

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 noted above, PEB reliance on the USAPDA pain policy was operant in this case and the CI’s condition was adjudicated independently of that policy by the Board.  In the matter of the chronic left knee and ankle pain, the Board recommends by majority decision, no change in the PEB adjudication.  The single voter for dissent did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131228, 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, AR20150007042 (PD201400548)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA