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AF | PDBR | CY2012 | PD2012 00922
Original file (PD2012 00922.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1200922   SEPARATION DATE: 20040831
BOARD DATE: 20130508


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PVT/E-2 (11B10/Infantry), medically separated for chronic bilateral knee pain due to patellofemoral syndrome (PFS). He first noted bilateral knee pain in January 2001 without any specific trauma. An orthopedic surgeon diagnosed him with patellofemoral pain syndrome (PFPS). Despite steroid injections, muscle relaxers and physical therapy the CI could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Anxiety disorder condition, identified in the rating chart below, was also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the bilateral knee condition as unfitting, rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining condition was determined to be not unfitting and therefore not rated. The CI made no appeals, and was medically separated with a 10% disability rating.


CI CONTENTION: “I WAS MISDIAGNOSED FOR PTSD AND TOLD IT WAS AN ANXIETY DISORDER. I WAS NOT DIAGNOSED FOR SLEEP APNEA BECAUSE THEY DID NOT RUN A TEST, BUT I HAVE SINCE BEEN DIAGNOSED. I WAS NOT DIAGNOSED PROPERLY FOR MY MIGRAINES OR FOR MY BACK CONDITION EVEN THOUGH THESE ARE PRESENT IN MY SERVICE MEDICAL RECORDS.”


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The posttraumatic stress disorder (PTSD) condition claimed and diagnosed by the MEB as anxiety disorder, as requested for consideration, meets the criteria prescribed in DoDI 6040.44 for Board purview; and, is addressed below, in addition to a review of the rating for the unfitting knee condition. The other requested back, sleep apnea and migraine conditions are not within the Board’s purview. 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 respective Service Board for Correction of Military Records.


RATING COMPARISON:

Service IPEB – Dated 20040616
 VA (4 Mos. Post-Separation) – All Effective Date 20040901
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Knee Pain due to PFS
 5099-5003 10% Right Knee PFS 5099-5024 0% 20050108
Left Knee PFS 5099-5024 0% 20050108
Anxiety Disorder
 Not Unfitting PTSD 9411 30% 20050108
↓No Additional MEB/PEB Entries↓
 0% X 3 / Not Service-Connected x 3 20050108
Combined: 10%
 Combined: 30%
* 20070426 VARD updated PTSD rating to 50% and Rt Knee Patellofemoral Syndrome rating to 10% effective 20050509 bringing the combined disability rating to 60%.

ANALYSIS SUMMARY:

Bilateral Knee Condition. The narrative summary (NARSUM) notes the CI developed bilateral knee pain in January 2001, during basic training. After conservative treatment, orthopedic surgery diagnosed bilateral PFS following a computerized tomography (CT) scan in September 2002. The CI underwent physical therapy (PT) and wore a knee brace. Upon return from deployment he was permanently profiled L3 for knee pain only and referred to the MEB. In February 2004 his commander’s statement noted that the CI was physically unable to perform the field duties of his MOS due to chronic knee problems. No other conditions were identified in the commander’s statement.

The goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.

Knee ROM
 MEB ~6 Mo. Pre-Sep VA C&P ~4 Mo. Post-Sep
Left Right Left Right
Flexion (140⁰ Normal)
 128⁰ 128⁰ 124⁰ 114⁰
Extension (0⁰ Normal)
 0⁰ 0⁰ 0⁰ 0⁰
Comment
 Positive patellar apprehension sign; no instability Bilateral pain, fatigue, weakness during repetitive motion, pain had the greatest functional impact
§4.71a Rating (§4.59)
10 % 10 % 10 % (VA 0%) 10 % (VA 0%)

At the MEB exam, 6 months prior to separation the CI reported daily bilateral knee pain, right greater than left , and greater than 80% of the day. He report ed that his pain was worse with prolonged standing or running and he ha d pain with prolonged walking . The CI stated ha d difficulty with marching, running, rucksack marching, working on a Bradley, or climbing onto equipment. Regarding Army duties, he report ed he ha d difficulty with running or jumping. The MEB physical exam noted motor strength was intact at 5/5, no varus or valgus deformity, negative anterior and posterior drawer, negative McMurray's test and p ositive patellar apprehension sign.

At the VA Compensation and Pension (C&P) exam, 4 months post-separation, the CI reported he had pain in both knees every day; the right lasting about four h ours and at worst the pain is 8 out of 10; and the left lasting about 6 hours. The CI stated that he could walk one side of city block, but cannot run or jump nor could he stand more than 15 minutes. The examiner documented he used a cane about once a week when “his flare-up is real bad.” The CI denied any episodes of dislocation or recurrent subluxation of either knee and stated that he was currently unemployed as he could not meet the physical demands of long periods of standing or lifting secondary to his knees. Regarding the left knee, the CI further noted it gave him pain, weakness, stiffness, swelling, giving way, locking, fatigability, and lack of endurance. He indicated the pain in his left knee starts out as a sharp pain in the joint and then becomes a dull pain as the pain gets worse. The examiner noted there was some tenderness medially just above the joint line of the left knee but there was no redness, heat , or abnormal movement noted other than the limitation in ROM as discussed below. At this exam, the VA examiner found no varus or valgus joint laxit y in either knee and that for both knees both McMurray's and Lachman's tests were negative. The VA examiner stated “the veteran was able to squat however he had a lot of pain while performing the duck waddle.” He determined the CI’s quadriceps strength to be 5/5 for both knees. During ROM testing, the examiner noted the CI had bilateral pain throughout all ROM and that popping was heard in both knees. During repetitive ROM , the CI was noted to display facial grimacing and following repetition, complained of pain, fatigue and weakness bilaterally with pain having the major functional impact. No edema, effusion, instability, or weakness was noted in either knee but the examiner did detect some guarding of mov ement during ROM.

The Board directs attention to its rating recommendation based on the above evidence. The Board’s noted the Informal PEB (IPEB) bundled the right and left knee together. The PEB combined the right knee chronic knee pain due to PFS and left knee chronic knee pain due to PFS conditions under a single disability rating, coded analogously to 5003 and rated IAW the USAPDA pain policy. 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, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled. Members agreed therefore that each knee should be conceded as reasonably separately unfitting; and, that coding and rating features were logically identical.

The VA rating of 0% for each knee coded 5099-5024 (tenosynovitis) cited a non-compensable evaluation without objective evidence of painful or limited motion. However, the source C&P exam clearly documented painful motion IAW DeLuca criteria. The Board considered the extensive nature of the C&P exam including consideration of DeLuca criteria, and opined that the VA exam had the higher probative value. The source VA exam clearly documented painful motion of each knee without evidence of instability warranting a 10% rating for each knee IAW VASRD §4.59 (painful motion), each coded 5099-5003.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends each knee as unfitting and a disability rating of 10% for the right knee condition and 10% for the left knee condition.

Contended PEB Conditions. The contended condition adjudicated as not unfitting by the IPEB was the PTSD condition diagnosed by the MEB as anxiety disorder. The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board deliberated if any mental health disorder rose to the level of being unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The mental health condition was effectively treated at the time of separation, was not profiled (S1); and there was no behavioral or mental health duty impact implicated in the commander’s statement. The mental health condition was not judged to fail retention standards. The anxiety disorder and PTSD conditions were reviewed by the action officer and considered by the Board. There was no indication from the record that any mental health condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the anxiety condition (or any mental health condition/PTSD) and, therefore, no additional disability rating can be recommended.


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 chronic bilateral knee pain due to PFS was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the service-combined chronic bilateral knee pain due to PFS condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows: right knee PFS coded 5099-5003 with a disability rating of 10%, left knee PFS coded 5099-5003 with a disability rating of 10%; both IAW VASRD §4.71a. In the matter of the contended anxiety disorder (PTSD) condition the Board unanimously recommends no change from the PEB determination as not unfitting. 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:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Bilateral Knee Pain due to Patellofemoral Syndrome
 Right 5099-5003 10%
Left 5099-5003 10%
COMBINED (w/ BLF)
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120529, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130010787 (PD201200922)
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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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