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AF | PDBR | CY2013 | PD 2013 01065
Original file (PD 2013 01065.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-01065
BRANCH OF SERVICE: Army  BOARD DATE: 20140430
SEPARATION DATE: 20040829


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (92Y30/Unit Supply Specialist) medically separated for bilateral knee condition. In 1994, the CI injured both knees during an airborne operation. She was treated conservatively and complained of continued knee pain intermittently with increased pain with running over the next 5 years. In 2000, she underwent an arthroscopy on the left knee, however she continued to have left knee pain. In 2002, she underwent a repeat arthroscopy of the left knee and several other simultaneous procedures on the same knee. Nevertheless, she complained of continued left knee pain. In 2004, she also began to complain of right knee pain, apparently due to overcompensation. Her bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The bilateral knee condition, characterized as “chronic patellofemoral pain syndrome of bilateral knees, left greater than right” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated chronic bilateral knee pain as unfitting, rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “I had multiple unfitting conditions affecting my ability to serve; not all was considered in my final disability rating at time of discharge.”


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 knee pain condition is addressed below. Any other condition or contention not requested in this application remains eligible for future consideration by the Board for Correction of Military Records. The Board acknowledges the CI’s contention that suggests ratings should have been conferred for other conditions documented at the time of separation. The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. However the Department of Veterans Affairs, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically reevaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.


RATING COMPARISON :

Service IPEB – Dated 20040505
 VA - (~ 4.5 Mos Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Knee Pain 5099-5003 10% Degenerative Joint Disease Left Knee 5010 10% 20040415
Degenerative Joint Disease Right Knee 5010 10% 20040415
Residual Scarring Left Knee Surgeries 7804 10% 20040415
No Additional MEB/PEB Entries
 Other x 5 20040415
Combined: 10%
 Combined: 80%
*Derived from VA Rating Decision (VARD) dated 20040910 (most proximate to date of separation (DOS))


ANALYSIS SUMMARY: The PEB combined the right and left knee pain conditions as a single unfitting condition coded analogously to 5003 and rated 10% with application of the USAPDA pain policy. The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications. The Board also noted that “bundling,” the combining of two or more major joints is permissible under the VA Schedule for Rating Disabilities (VASRD) 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings. The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. When considering a separate rating for each condition, the Board considers whether each bundled condition is reasonably justified as separately unfitting by a preponderance of the evidence. When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

The CI suffered bilateral knee injuries in June 1994 during airborne operations. She had continued knee pain intermittently over the next 5 years with increased pain with running. On 19 November 1999, a physical therapy follow up note cited a magnetic resonance imaging study (MRI) which showed left knee chondromalacia at that time. The CI then had the first left knee surgical meniscal repair and chondromalacia repair in June 2000. She developed progressively worse left knee pain after the first surgery. On 19 June 2002, the CI underwent a second left knee arthroscopy, chondro-picking medial femoral condyle, lateral retinacular release and Fulkerson’s osteotomy - patellar realignment procedure. She continued with pain of the left knee. The right knee became painful upon running and walking in about January 2004. She was then re-evaluated by orthopedics and a MEB was initiated for bilateral retropatellar pain left greater than right in about February 2004.

Chronic Left Knee Pain. The commander’s statement on 4 March 2004 remarked that the CI was unable to perform her military duties due to her chronic left and right knee problems. She was unable to pick up, issue or receive most supplies. She had problems walking, standing, and bending her legs and unable to participate in any physical training other than swimming. The profile on 11 March 2004 was for chronic knee pain, permanent lower extremity level three profile (L3), with limitations of no running, no jumping, no road marching, no backpack (40 pounds), or standing greater than 30 minutes per hour and no lifting over 40 pounds.

At the MEB narrative summary (NARSUM) examination on 1 April 2004, about 4 months prior to separation, the CI reported she had continued left and right knee pain and had been on profile since September 2000. She was unable to lift over 10 pounds without pain. She could not walk, stand, or sit for prolonged periods. The CI had pain when entering and exiting vehicles, getting in and out of the bath tub, and was unable to kneel while praying in church or to skate with her children. Physical examination revealed mild effusion of the left knee, and tenderness on the medial and lateral patellar borders. A patellar grind test was positive bilaterally. There was negative medial joint line tenderness, negative anterior drawer sign and a negative Lachman’s test. There was no pivot shift, and no laxity with varus and valgus stress. Range-of-motion (ROM) was equal bilaterally from 0 to 125 degrees (normal 0-140).

At the VA Compensation and Pension (C&P) general exam on 15 April 2004, also about 4 months prior to separation, the CI reported constant pain that felt “like bounding and grinding,” but was not causing incapacitation or time lost from work. Physical examination revealed normal posture and gait, normal leg lengths and no signs of abnormal weight bearing. Right and left knee appearance was normal. There was an elevated surgical scar on the left knee measuring 11 cm by 0.5 cm, with tenderness and hyperpigmentation, but no disfigurement, no ulceration, no adherence, no instability, no tissue loss, no keloid formation, no hypopigmentation, no abnormal texture, and no limitation of motion. There was bilateral crepitus, a negative drawer test and negative McMurray’s test. Gross examination of muscles was within normal limits. Right knee ROM was 0-140 (normal) with pain at 140 degrees. Left knee ROM was 0-120 with pain at 120. Neither was additionally limited by fatigue, weakness, lack of endurance or incoordination. Bilateral knee X-rays on 15 March 2004, showed mild bilateral knee osteoarthropathy, and postsurgical changes with multiple screws through the proximal tibial metaphysis of left knee.

The Board first considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting. Members agreed that the functional limitations in evidence justified the conclusion that the left knee condition prevented the CI from performing her MOS duties and, therefore a separate service rating is recommended.

The Board directs attention to its rating recommendation. The Board considered VASRD codes 5099 (analogous rating to) – 5003 (arthritis, degenerative) used by the PEB for a 10% bilateral rating. The Board also considered code 5010 (arthritis due to trauma) used by the VA for a 10% rating. The VASRD instructs to rate code 5010 (arthritis due to trauma) as code 5003 (arthritis, degenerative). The Board found evidence of painful motion and X-ray abnormalities for a 10% rating using code 5003. The Board did not find evidence of a ratable limitation of motion, for a higher rating than 10%, under codes 5256 (knee, ankylosis of), 5260 (leg, limitation of flexion of), 5261 (leg, limitation of extension of), or 5262 (tibia and fibula, impairment of). The Board also considered code 5259, cartilage, semilunar, removal of, symptomatic, but it did not provide a rating advantage either. There were no episodes of recurrent subluxation or lateral instability for a higher rating under code 5257 (knee other impairment of). The Board did not find evidence of significant additional or independent functional limitations imposed by the surgical scars of the left knee to support addition of surgical scars of the left knee as a separately unfitting condition. There was also no evidence to use the alternate code 7804 (scars, unstable or painful) for a rating in the CI’s favor. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic left knee pain condition coded 5099-5003.

Chronic Right Knee Pain: On 13 January 2004, 7 months prior to separation, a primary care clinic note documented the CI was referred to orthopedics because she had developed new right knee discomfort and pain with running, and walking normally. Orthopedic consultation on 10 February 2004 documented the diagnosis of patello-femoral pain syndrome, bilateral, left greater than right. The orthopedist considered MEB at that time. The physical examination showed an antalgic gait with left knee swelling and tenderness and full active bilateral ROM with pain. X-rays of the right knee showed a slightly high-riding patella and mild knee osteoarthropathy. MRI of the right knee on 23 February 2005, 6 months after separation, revealed chondromalacia of the medial articulating facet of the patella. NARSUM and C&P physical exam findings and ROM were summarized above.

The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting. The commander’s statement implicated both the right and left knee as preventing the CI’s completion of her military duties. The profiled limitations were for knee pain and presumed to be bilateral. Members agreed the limitations were reasonably applicable to either knee without resorting to mere speculation, and that the functional limitations in evidence justified the conclusion that the right knee condition was separately unfit. Accordingly, a separate service rating is recommended.

The Board directs attention to its rating recommendation. The PEB used VASRD codes 5099 (analogous rating to) – 5003 (arthritis, degenerative) for a 10% bilateral rating. The VA used code 5010 (arthritis due to trauma, which the VASRD instructs to rate as 5003 (arthritis, degenerative), for a VA rating of 10% for the right knee condition. The Board found satisfactory evidence of painful motion (measured at 0-140 with pain at 140) and X-ray findings of a high-riding patella and mild knee osteoarthropathy for a minimal rating of 10% by using code 5003. There was no evidence of occasional incapacitating exacerbations, joint instability, joint subluxation, or ROM limitations for a possible higher rating under alternate codes. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic right knee pain 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 the chronic bilateral knee pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the chronic right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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 her prior medical separation:

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



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130723, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record



                                   
XXXXXXXXXXXXXXX
President
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, AR20140020812 (PD201301065)
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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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