RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02716
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150715
SEPARATION DATE:  20070530  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Wheeled Vehicle Mechanic) medically separated for bilateral knee pain.  The condition 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).  The conditions “plica syndrome” and “petellofemoral syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic bilateral knee pain due to plica syndrome and patellofemoral syndrome [PFS]” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.”

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 conditions 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/Naval 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:  

IPEB – Dated 20070530 | VA* - (~8 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Bilateral Knee Pain ... | 5099-5003 | 10% | Right Knee PFS | 5260 | 10% | 20080128
| | | Left Knee PFS | 5260 | 10% | 20080128
Other MEB/PEB Conditions x 0 (Not In Scope) | Other x 4
RATING:  10% | RATING:  20%
*Derived from VA Rating Decision (VARD) dated 20080312 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Bilateral Knee Condition.  The service treatment record (STR) corroborates the history in the narrative summary (NARSUM) of an atraumatic onset of bilateral knee pain in 2003, which worsened over time in spite of temporary profiles and conservative treatment.  The right knee was somewhat more symptomatic than the left.  The CI was diagnosed with PFS and chondromalacia patella (damage to the cartilage under the knee cap).  Initial magnetic resonance imaging (MRI) was normal; although an MRI shortly before separation demonstrated some mild meniscal damage on the right.  There were no surgical indications.  Various STR entries document normal gait, grossly normal range-of-motion (ROM), stability to stress testing, negative signs of impingement, and the absence of effusions (bilateral).  There was no documentation of any periods of incapacitation.  

The NARSUM was conducted 5 April 2007 (2 months pre-separation), and documented constant bilateral knee pain rated at 4/10 with exacerbations to 8/10 by weight loads, prolonged standing, running, and marching.  The NARSUM physical examination recorded some bilateral knee tenderness, normal strength, and no effusion without comment regarding instability or impingement.  The NARSUM cited physical therapy ROM measurements (bilateral) of 120 degrees flexion (normal 140, minimum compensable 45) and extension 0 degrees (normal), annotating painful motion.

A VA Compensation and Pension (C&P) examination was conducted 28 January 2008 (8 months post-separation), and documented constant bilateral pain rated 6/10 with exacerbations to 10/10 by repetitive motion, squatting, and “physical labor, such as moving furniture.”  The examiner noted “occasional locking” of the right knee, but no effusions or instability.  The VA physical examination recorded a normal gait, right patellar tenderness, negative effusion, stability to stress testing in all planes, negative signs of impingement, and strength 4+/5 on the right and 5/5 on the left.  The VA measured ROM was bilateral flexion to 130 degrees and extension 0 degrees, annotating painful motion with repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s bilateral 10% rating analogous to 5003 (degenerative arthritis) was under the USAPDA pain rule, but was compliant with VASRD §4.71a criteria under 5003 for two or more major joints.  The VA’s separate 10% determinations under 5260 (limitation of flexion) cited painful motion to achieve the minimum compensable ratings.  There was no compensable ROM impairment or instability which would achieve separate ratings higher than 10%.  The occasional locking of the right knee referenced by the VA examiner does not satisfy the 20% criteria under code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) since there was no objective signs of impingement and the requisite criterion of frequent effusions was not satisfied by the evidence.  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each disability rating.  

In this case, especially considering that it can be argued that the left knee was very dubiously justified as separately unfitting, member consensus was that it was fair to surmise that it was the combined impairment from both joints which rendered the CI unfit; and, thus the §4.71a compliant bilateral 10% rating under 5003 is appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board consensus was that there was insufficient cause to recommend a change in the PEB adjudication of the bilateral knee 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 was operant in this case and it was adjudicated independently of that policy by the Board.  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board by a majority vote 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 re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140606, 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, AR20150015458 (PD201402716)

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

PD-2014-02716