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AF | PDBR | CY2012 | PD2012 01519
Original file (PD2012 01519.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE NUMBER: PD1201519
BRANCH OF SERVICE: Army  BOARD DATE: 20130411
Separation Date: 20020613


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (11B/Infantry) medically separated for bilateral patellofemoral pain syndrome (PFS). The CI had progressively worsening bilateral knee pain after an airborne operation jump in Germany in 1993. The CI also injured the right knee when it twisted during pugil stick training in 1993. Despite a left knee arthroscopy, physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs), and orthopedic evaluations, the CI could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards. The CI He was issued a permanent L3 profile in May 2001 and referred for a MOS/Medical Retention Board (MMRB) in Korea. The results of this Board are not available in the record; however, the CI was sent to CONUS for a Medical Evaluation Board (MEB). The MEB forwarded “Bilateral Knee Pain consistent with patellofemoral pain syndrome” to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “Bilateral Patellofemoral Pain Syndrome Not Requiring Daily Narcotics” as unfitting and rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The disability was designated as a combat related injury based on the injury to the right knee during pugil training. The CI made no appeals and he was medically separated with a 10% disability rating.


CI CONTENTION: “Incomplete initial findings by original PEB in Korea. Knees should have been rated separately, not together. R ankle was worse than rated.” He does not elaborate further or specify a request for Board consideration of any additional conditions.


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in Department of Defense Instruction (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 requested condition of the right ankle was not identified by the PEB and is therefore not within the 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 the Correction of Military Records.


RATING COMPARISON :

Service PEB – Dated 20020510
 VA (used service treatment records) – Effective 20020614
Condition
 Code Rating Condition Code Rating Exam
Bilateral PFS 5099-5003 10% PFS, Left Knee 5260 10% STRs
PFS, Right Knee 5260 10% STRs
↓No Additional MEB/PEB Entries↓
 0% X 2 / Not Service Connected x 2
Combined: 10%
 Combined: 20%

ANALYSIS SUMMARY: The Board acknowledges the CI’s assertions that the original PEB had incomplete initial findings and that the knees should have been rated separately. It is noted for the record that the Board has neither the jurisdiction nor authority to scrutinize or render opinions in reference to the CI’s statements in the application regarding suspected improprieties in the processing of his case. 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.

Bilateral Patellofemoral Pain Syndrome Condition. The PEB rated left knee and right knee PFS 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.

The Board first considered if both the left and right knee conditions, having been de-coupled from the combined PEB adjudication, were each reasonably justified as independently unfitting. The service treatment record (STR) includes a long history of right knee pain after an injury in 1993 with intermittent visits, temporary profiles, and a permanent L2 profile for right knee pain in 1996. In June 1999, the CI also complained of left knee pain and swelling. Magnetic resonance imaging (MRI) of the left knee suggested a meniscal injury. However, arthroscopy of the left knee in May 2000 noted a fissure of the lateral tibial plateau and no meniscal injury. The bilateral knee pain continued and the permanent L2 profile was increased to an L3 for knee arthralgias and ankle reconstruction. The CI then underwent an MMRB and he was subsequently referred for an MEB. The L3 profile does not specify whether one or both knees were involved; however, it appears to include both knees. The orthopedic treatment note in October 2001 for MEB initiation and the MEB NARSUM both have bilateral PFS as the diagnosis. The MEB and the PEB also both refer to bilateral knee PFS. The commander’s statement does not mention any specific condition but states the CI’s permanent profile limitations prevent him from performing in his primary MOS. Therefore, it is reasonably justified that the CI be found unfit for continued military service in his MOS due to his left and right knee PFS condition. All members agreed that both the left and right knee PFPS conditions, as isolated conditions, would each have rendered the CI incapable of continued service within his MOS, and accordingly each knee 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.
invalid font number 31502


invalid font number 31502
Knee ROM
(In degrees)
Ortho ~ 8 Mo. Pre-Sep MEB ~4. 5 Mo. Pre-Sep
Left Right Left Right
Flexion (140 Normal)
 FAROM FAROM 0- 140 0- 140
Extension (0 Normal)
 0 0 0 0
Comment
No effusion; negative varus/valgus; negative anterior drawer, Lachman, pivot shift; negative McMurray; + Steinmann quadriceps inhibition test; “bilateral knee pain”		 No effusion; no instability with varus or valgus stressing; negative : anterior drawer, Lachman, pivot, sag, and McMurray
+ Steinmann quadriceps inhibition test; neurovascularly intact; x-rays negative; “bilateral knee pain”
§4.71a Rating
 10% (Painful Motion) 10% (Painful Motion) 10% (Painful Motion) 10% (Painful Motion)

The CI’s right knee pain started in 1993 with the right knee being twisted during pugil stick training. The right knee pain continued and an MRI performed in 1994 showed right knee degenerative changes. The orthopedics consult indicated new onset of left knee, swelling and tenderness. The left knee MRI in 1999 suggested medial meniscal degeneration in the posterior horn. The CI underwent a left knee arthroscopy in 2000. The operative report is not available but follow-up visits note a left knee fissure of the lateral tibial plateau. The CI was seen in follow-up by orthopedics approximately 8 months prior to separation and this examination noted bilateral knee pain with a bilateral positive Steinmann test and no instability. The commander’s statement indicated that the CI was unable to perform his MOS activities. The MEB narrative summary (NARSUM) examination completed approximately 4 months prior to separation documented constant bilateral knee pain with the left knee worse that the right which caused the CI’s activities to be severely restricted. The MEB NARSUM physical exam findings are summarized in the chart above.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the bilateral PFS analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) rated 10% IAW with the USAPDA pain policy. The VA coded each knee 5260 leg, limitation of flexion of and assigned a 10% rating to each knee. The VA based their disability rating on the STR, as there was no Compensation and Pension (C&P) examination performed. All exams met the 10% criteria rating for each knee with application of VASRD §4.10 functional impairment, §4.40 functional loss, §4.45 the joints, and §4.59 painful motion. Neither coding scheme offers an advantage. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends a rating of 5260 at 10% for the left knee PFS condition and 5260 at 10% for the right knee PFS 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 bilateral PFS was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the bilateral PFS conditions, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting PFS left knee condition coded 5260, rated 10% and an unfitting PFS right knee condition 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
Patellofemoral Pain Syndrome, Left Knee 5260 10%
Patellofemoral Pain Syndrome, Right Knee 5260 10%
COMBINED (w/BLF)
 20%
______________________________________________________________________________

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120605, 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 AR20130010201 (PD201201519)


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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