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AF | PDBR | CY2012 | PD2012 01223
Original file (PD2012 01223.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1201223   SEPARATION DATE: 20020729
BOARD DATE: 20120515


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63T10/Bradley Fighting Vehicle Mechanic) medically separated for a knee condition. He developed an atraumatic onset of right knee pain in 2000, soon after completing basic training. This gradually worsened, was associated with less severe left knee pain, and was diagnosed as patellar tendinitis. The condition 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). The condition, characterized as “chronic patellar tendinitis, bilateral knees,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. Lumbar and hearing conditions, as charted below, were also identified and forwarded by the MEB as meeting retention standards. The PEB adjudicated “chronic bilateral patellar tendinitis (tenosynovitis)” as unfitting, rated 0%, citing criteria of the Veterans Administration Schedule for Rating Disabilities (VASRD) with possible application of the US Army Physical Disability Agency pain policy. The remaining conditions were determined to be not unfitting, not ratable. The CI made no appeals and was medically separated with a 0% disability rating.
CI CONTENTION: The application states simply, “Knee, back, hearing”


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 knee conditions is addressed below. The requested low back pain and hearing loss conditions, which were determined to be not unfitting by the PEB, are likewise addressed below. Those, and any other conditions or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records. The Board acknowledges the CI’s contention for ratings of the lumbar and hearing conditions which were determined to be not unfitting by the PEB but notes that disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that any contested condition was likely incompatible with duty requirements, a Service disability rating IAW the VASRD, and based on the degree of disability evidenced at separation, will be recommended.



 RATING COMPARISON :

Service IPEB – Dated 20020624
 VA (10 Days Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Patellar Tendinitis 5024 0% Tendinitis/Chondromalacia, R Knee 5099-5014 10% 20020808
Chondromalacia Patella, L Knee 5099-5014 0% 20020808
Intermittent Low Back Pain Not Unfitting Lumbosacral Spine Strain 5295 10% 20020808
High-Frequency Hearing Loss Not Unfitting Hearing Loss, L Ear 6100 0% 20020808
Hearing Loss, R Ear 6100 NSC 20020808
Tinnitus 6260 10% 20020808
No Additional MEB/PEB Entries
 0% X 2 Additional / NSC X 1 Additional 20020808
Combined: 0%
 Combined: 30%
Derived from VA Rating Decision (VARD) dated 20021126 ( most proximate to date of separation [DOS]).


ANALYSIS SUMMARY:

Bilateral Knee Condition. The earliest entry in the service treatment record (STR) was a complaint of left knee pain without injury in March 1999. The CI developed right knee pain after running in June 2000, was treated conservatively, and was issued a temporary profile. He improved adequately but in 2001 his symptoms worsened. X-rays were normal. An orthopedic consultant in April 2002 diagnosed bilateral patellar tendinitis (non-surgical), noted that conservative treatment measures had been exhausted, and recommended a MEB. Outpatient STR entries documented grossly normal range-of-motion (ROM) bilaterally, ligamental stability, and no signs of cartilage impingement. Right knee pain was the dominant complaint in earlier entries, although bilateral knee pain appears in later entries. The orthopedic addendum to the narrative summary (NARSUM) addressed “bilateral anterior knee pain,” making no distinction between right and left severity. The NARSUM (a month after the orthopedic addendum) focused on right knee pain, stating that the left knee “is currently only minimally symptomatic.” The NARSUM noted that the CI was “unable to do tasks requiring squatting, climbing onto and off of military vehicles, heavy lifting, kneeling, or crawling.” Both the NARSUM and orthopedic examiners noted anterior tenderness and patellar grind (bilaterally) on physical exam. Both examiners documented the absence of effusion, stability with stress testing, and there were no signs of cartilage impingement. Both examiners recorded normal bilateral flexion (140 degrees) on ROM measurement, and neither commented on painful motion. At the VA Compensation and Pension (C&P) evaluation right after separation, the examiner addressed each knee separately. For the right knee, he recorded “knee pain on a daily basis increased by walking, running, and bike riding ... [stair climbing] ... flares up two to three times a week and lasts for a whole day.” For the left knee, “He complained of pain on and off two to three times a month and may last for a day or two.” The examiner added, “The right and left knee pain and flare-up does not significantly limit his regular functional activities.” The VA physical exam noted a normal gait; “grinding and popping” of the right knee, but not the left; tenderness to patellar compression on the right, but not the left; and no effusion, instability, or signs of cartilage impingement for either knee. The VA ROM measurements were normal extension (0 degrees) bilaterally, 130 degrees flexion on the right, and 140 degrees flexion on the left. For each knee the examiner specified “no associated pain” with motion.

The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the right and left knee conditions under a single disability rating, coded 5024 (tenosynovitis) which defaults to rating criteria of 5003 (degenerative arthritis). Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” joint can be reasonably justified as separately unfitting in order to remain eligible for service rating. The evidence makes clear that the right knee was associated with more disability than the left one in this case. As noted above, the right knee dominated most of the clinical course. The NARSUM clearly expressed that right knee pain was the primary source of difficulty. The C&P exam (the most probative evidence closest to the separation date) documented that the right knee caused daily problems whereas the left knee caused problems only a few days per month, and physical findings were more prominent on the right. Although both knees were profiled, after due deliberation, members agreed the evidence did not support a conclusion that the functional impairment from the left knee was integral to the CI’s inability to perform his MOS and so cannot recommend a separate rating for it.

Having agreed that only the right knee was reasonably justified as unfitting, members deliberated the appropriate code and rating recommendation. The PEB’s code 5024 is appropriate to the pathology (tenosynovitis), but does not overcome §4.71a barriers to a 10% rating. The modest ROM reduction noted in the probative C&P does not reach the 10% threshold for rating under code 5260 (limitation of knee flexion), although members agreed that application of either VASRD §4.59 (painful motion) or §4.40 (functional loss) is supported to achieve the minimal compensable rating. There is no evidence of ligamental laxity, frequent effusions, or other ratable findings which would support more than a 10% rating under any of the §4.71a knee joint codes, or separate rating for instability. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the right knee condition, agreeing that a code designation of 5024-5260 most appropriately reflects the diagnosis and rating criteria.

Contended Lumbar and Hearing Conditions. The CI's back condition developed shortly before separation and was never permanently profiled. His hearing condition was only limited to an H2 profile and he was placed in the hearing conservation program. The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. 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. Neither of these conditions was implicated in the commander’s statement and neither was judged to fail retention standards by the MEB. Both were reviewed by the action officer and considered by the Board. There was no indication from the record that either of them 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 either of the contended conditions and therefore, no additional disability ratings 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. In the matter of the service-combined bilateral knee condition, the Board unanimously recommends a rating of 10% for an unfitting right knee condition coded 5024-5260 IAW VASRD §4.71a; but, unanimously agrees the left knee condition was not separately unfitting and thereby not subject to disability rating. In the matter of the contended lumbar and hearing loss conditions, the Board unanimously recommends no change from the PEB determinations 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
Right Knee Tendonitis 5024-5260 10%
Left Knee Tendonitis Not Unfitting
Intermittent Low Back Pain Not Unfitting
High Frequency Hearing Loss Not Unfitting
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120702, 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 AR20130012544 (PD201201223)
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 10% 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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