Search Decisions

Decision Text

AF | PDBR | CY2012 | PD2012 01228
Original file (PD2012 01228.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE NUMBER: PD1201228
BRANCH OF SERVICE: Army  BOARD DATE: 20130426
Separation Date: 20020228


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (51M/Firefighter) medically separated for a bilateral knee pain condition. The CI had an insidious onset of bilateral knee pain in 1999. Despite left knee steroid injections extensive physical therapy (PT) rehabilitation and non-steroidal anti-inflammatory drugs (NSAIDS), and bilateral arthroscopic lateral releases the CI could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. The CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded bilateral retropatellar pain syndrome (RPPS) and lateral patellar compression syndrome condition to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “Bilateral Retro Patellar Pain Syndrome, Status Post (S/P) Arthroscopic Release with only Moderate Improvement” condition as unfitting, rated 0%, citing criteria of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 0% disability rating.


CI CONTENTION: “Right and left conditions (2 surgeries on each knee), PTSD, Sinusitis, Tinnitus % per VA. Limited Flexion of knee – 10% service connected, Allergic or Vasomotor Rhinitis – 10% service connected, PTSD – 30% service connected, Tinnitus 10% - service connected, lower leg condition – 20% service connected.”


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 bilateral RPPS condition is addressed below. The requested allergic or vasomotor rhinitis, posttraumatic stress disorder (PTSD), tinnitus, and lower leg conditions were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records.



 RATING COMPARISON :

Service IPEB – Dated 20020116
 VA - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Retropatellar Pain Syndrome S/P Arthroscopic Release with only Moderate Improvement 5099-5003 0% Right Knee Patellar Compression Syndrome w/History of Arthroscopic Lateral Release 5299-5262 10% 20020429
Left Knee Patellar Compression Syndrome w/History of Arthroscopic Lateral Release 5299-5260 Not Service Connected
(NSC)*		 20020429
No Additional MEB/PEB Entries
 Other x 9 20020429
Combined: 0%
 Combined: 10%
Derived from VA Rating Decision (VARD) dated 20020508 (most proximate to date of separation [DOS]).
*VARD 20060105 DRO service connected and rated left knee 10% effective 20040804.


ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

The PEB rated right and left knee RPPS under the single analogous 5003 degenerative arthritis code. This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation. The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as unfitting in and of itself, with the caveat that the final recommendation may not produce a lower combined rating than that of the PEB.

Right and Left Knee Retropatellar Pain Syndrome status post Arthroscopic Release with Only Moderate Improvement Condition. The Board first considered if the left and right knee RPPS conditions, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above. The CI was on a permanent profile with significant limitations that would have resulted from either condition alone. The service treatment record (STR) notes initial visits for right knee pain in 1998, left knee pain in April 2000, and bilateral knee pain in October 2000. Arthroscopy with lateral release was required for each knee with the left knee surgery performed in March 2001 and the right knee surgery performed in August 2001. Abrasion chondroplasty was also performed on the left knee. Both knees were noted to have lateral patellar compression syndrome and the left knee also had Grade III chondromalacia of the medial patellar facet. However, the CI continued to have bilateral knee pain after surgery; he was issued a permanent profile for RPPS in November 2001 and was referred for an MEB. The commander’s statement notes the CI was unable to perform the duties of his MOS due to his knee problem. All members agreed that the left and right knee RPPS, as isolated conditions, would each have rendered the CI incapable of continued service within his MOS and each accordingly merits a separate rating.

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

“
Knee ROM
 (Degrees)
 MEB ~ 3.10 Mo. Pre-Sep VA C&P ~ 2.03 Mo. Post-Sep
Left Right Left Right
Flexion (140 Normal)
 120 120 140 130
Extension (0 Normal)
 5 0 0 0
Comment
 Marked crepitus with ROM; + Clark sign; medial and lateral facet tenderness to palpation (TTP); pain with patellar compression; normal patellar tracking and glide and patellar tilt normal; negative anterior and posterior drawer; negative Lachman’s; medial and lateral joint lines are nontender; patellar tendon is nontender to palpation; no effusionsPain with motion”; Wears shoe inserts; negative drawer sign; no lateral or medial instability
No change with repetitive motion; + crepitus with ROM; Flexion limited by pain; repetitive motion flexion 130, then third time to 140; no redness, warmth, or effusion; patella slides freely
Lateral femoral condyle slight TTP; normal Q angle; no laxity with valgus or varus stressing at 0 and 30 degrees
§4.71a Rating
 10% 10% 10% 10%

The CI continued to have mild to moderate bilateral knee pain after the two surgeries described above. He received two steroid injections in the left knee in November 2001 without resolution of his pain. Physical therapy noted persistent bilateral mechanical knee pain with maximum pain rated at 8-9/10, pain at rest at 5/10, and the use of patellar stabilizing braces and orthotics. The MEB narrative summary (NARSUM) examination, approximately 3 months prior to separation, documented bilateral achy, throbbing and burning knee pain exacerbated by sitting, standing, marching, and going up and down stairs. The examiner opined that the CI had moderate to severe pain when doing activity. The MEB NARSUM exam findings are summarized in the chart above. The VA Compensation and Pension (C&P) examination approximately 2 months after separation documented continued bilateral knee pain, fatig ability, and lack of endurance with ambulation; th e need for shoe inserts because he inverted his feet with ambulation secondary to his bilateral knee problem; episodes of flares with running, squatting or knee l ing and walking up and downstairs. The C&P exam findings are summarized in the chart above . The examiner noted the CI was working as a youth care worker and was applying for a job as a firefighter.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the bilateral RPPS under the single analogous code 5099-5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated 0%. The VA coded the right knee patellar compression syndrome with history of arthroscopic lateral release analogous to 5262 tibia and fibula, impairment of at 10% for slight disability. The left knee patellar compression syndrome with history of arthroscopic lateral release, coded as 5299-5260, was initially determined to be not service-connected based on a lack of any complaint of pain with motion. The left knee condition was later service-connected effective 4 August 2004 (the date of the reopened claim), coded analogous to 5260, and rated at 10% based on painful motion noted during military service and on a C&P examination in December 2005. The initial C&P examination near the time of separation does not mention painful motion of the left knee on examination and full ROM was noted. However, the history reports continued chronic pain of both knees and flare-ups of this bilateral pain with activities involving bilateral knee motion such as squatting. With painful or pain-limited motion documented on examinations both prior to and after the initial C&P examination and a history compatible with painful motion at the initial C&P examination, the record provides adequate evidence to support a determination that, more likely than not, painful motion of left knee was present at the time of separation from service. The right knee had pain-limited motion at both the MEB NARSUM and the initial C&P examinations. Neither examination supports a rating greater than 10% for either knee. After due deliberation in consideration of the totality of the evidence, the Board concluded that the right and left RPPS were each separately unfitting. Considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt and §4.59 painful motion, the Board recommends a disability rating of 10% coded 5260 IAW VASRD §4.71a for the RPPS and 10% coded 5260 IAW VASRD §4.71a for the left RPPS.


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 bilateral RPPS condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right RPPS condition coded 5260 and rated 10% and an unfitting left RPPS, coded 5260 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:

UNFITTING CONDITION
 VASRD CODE RATING
Right Retropatellar Pain Syndrome status post Arthroscopic Release 5260 10%
Left Retropatellar Pain Syndrome status post Arthroscopic Release 5260 10%
COMBINED (w/BLF)
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120623, 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 AR20130010244 (PD201201228)


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

Similar Decisions

  • AF | PDBR | CY2012 | PD2012-00803

    Original file (PD2012-00803.docx) Auto-classification: Approved

    Bilateral Knee Pain . The knee pain condition was coded 5099-5003 and rated at 0%. Accordingly, the Board recommends a separate disability rating for each knee.

  • AF | PDBR | CY2012 | PD 2012 01073

    Original file (PD 2012 01073.txt) Auto-classification: Denied

    IAW VASRD §4.71a, the Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved. He followed up with orthopedics in June 2002; he again reported no improvement. The Board concluded that separating the bilateral knee condition into right and left knee conditions gave no rating advantage to the CI.

  • AF | PDBR | CY2012 | PD 2012 01001

    Original file (PD 2012 01001.txt) Auto-classification: Approved

    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 Army Board for Correction of Military Records. After due deliberation, considering all of the evidence and mindful of VASRD§ 4.3 (Resolution of reasonable doubt), 4.7 (Higher of two evaluations) and §4.45 (The joints); the Board recommends that the bilateral knee condition be rated for two separate unfitting conditions as...

  • AF | PDBR | CY2012 | PD-2012-01921

    Original file (PD-2012-01921.rtf) Auto-classification: Denied

    The MEB also identified and forwarded history of cellulitis, left knee, chronic bilateral hip pain secondary to bilateral iliotibial band friction syndrome, chronic mechanical low back pain, mild (less than a centimeter) left shorter than right limb length discrepancy, and mild bilateral pes planus conditions.The PEBadjudicated “left patellofemoral pain with secondary chronic left knee pain” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating...

  • AF | PDBR | CY2012 | PD2012 01126

    Original file (PD2012 01126.rtf) Auto-classification: Denied

    RATING COMPARISON : Service IPEB – Dated 20011102VA* - Service Treatment Records (STR)ConditionCodeRatingConditionCodeRatingExam Chronic Low Back Pain with Mild Compression Fracture of T12-L1 and Degenerative Lower Lumbar Disc Disease529510%DDD L5-S1 with Spondylolysis529310%STRChronic Retropatellar Pain SyndromeNot UnfittingRetropatellar Pain Syndrome; s/p Arthroscopy w/Residuals, Old Tear and Lateral Meniscus with Laxity or Lateral Collateral Ligament, Right...

  • AF | PDBR | CY2012 | PD2012 01525

    Original file (PD2012 01525.rtf) Auto-classification: Approved

    Left Knee . The Board noted that there was no pain on ROM testing on either the MEB or C&P examinations; however, both examinations made reference to tenderness about the patella and noted pain with activity implying painful motion. 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...

  • AF | PDBR | CY2013 | PD-2013-01828

    Original file (PD-2013-01828.rtf) Auto-classification: Approved

    Bilateral Knee Pain Secondary to Retropatellar Pain Syndrome . The treatment notes, history and specific diagnosis of “retropatellar pain syndrome” support painful motion for each knee. 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 bilateral knee pain secondary to...

  • AF | PDBR | CY2013 | PD2013 01479

    Original file (PD2013 01479.rtf) Auto-classification: Denied

    At the MEB examination on 2 June 2006 the CI reported bilateral knee pain. The MEB physical examiner also noted normal ROM, stable knees, and painful patellar compression. RECOMMENDATION : The Board recommends no re-characterization of the CI’s disability and separation determination.

  • AF | PDBR | CY2012 | PD 2012 00969

    Original file (PD 2012 00969.txt) Auto-classification: Denied

    The PEB adjudicated the chronic bilateral knee pain due to RPS condition as unfitting, rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. (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. ...

  • AF | PDBR | CY2014 | PD-2014-01939

    Original file (PD-2014-01939.rtf) Auto-classification: Approved

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. Left knee pain . The Board determined that, since the left knee was implicated in the Physical Profile (DA Form 3349), and in the commander’s performance statement dated 10 May 2004, it was appropriate to document the...