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AF | PDBR | CY2013 | PD-2013-01822
Original file (PD-2013-01822.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX             CASE: PD-2013-01822
BRANCH OF SERVICE: Army  BOARD DATE: 20141209
SEPARATION DATE: 20040430


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard PV2/E-2 (88M/Motor Transport Operator) medically separated for degenerative arthritis of the knees. The bilateral knees and left ankle condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was allowed to perform an alternate event to satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Bilateral knee degenerative joint disease (DJD), left greater than right and left ankle pain were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “degenerative arthritis of the knees,” as a single unfitting condition, rated at 10%, citi ng criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining condition (left ankle pain) was determined to be not unfitting and therefore not rat ed . The CI made no appeals and was medically separated.


CI CONTENTION: The CI listed: “Weakening in rt leg; high cholesterol; acid reflux disease; sleep apnea; numbness in rt back torso and rt elbow pain; pain in left ankle; PTSD>nightmares.”


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 degenerative arthritis of the knees is addressed below. The requested left ankle pain, which was determined to be not unfitting by the PEB, is likewise addressed below. The requested high cholesterol, acid reflux disease, sleep apnea, numbness in right back torso, right elbow pain and posttraumatic stress disorder were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. No additional conditions are 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 :

PEB Admin Corr – Dated 20040409
 VA - (5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Degenerative Arthritis of the Knees 5003 10% Degenerative Joint Disease, R Knee 5010-5260 10% 20040925
Degenerative Joint Disease, L Knee 5010-5260 10% 20040925
Left Ankle Pain Not Unfitting Left Ankle Sprain 5299-5270 0% 20040925
Other x 0 (Not in Scope)
 Other x 6
Rating: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 60614 (most proximate to date of separation)


ANALYSIS SUMMARY:

Degenerative Arthritis of the Knees. The CI was deployed to Kuwait and presented on 21 March 2003 with a 2-day history of left knee and ankle pain. He was treated with activity modification and anti-inflammatory medications. He continued to report bilateral knee and left ankle pain and was referred for an orthopedic evaluation in June 2003. At the orthopedic evaluation dated 28 August 2003, the CI reported bilateral knee pain that worsen with activity and left ankle pain. The physical examination the examiner noted full range-of-motion (ROM) for both knees without pain. There was swelling at the outer aspect of the left ankle with tenderness to palpation. Diagnoses of early DJD bilateral knees and ankle pain status post sprain were rendered. On 7 October 2003 the CI was removed from theater due to bilateral knee chronic DJD and left ankle DJD exacerbated by MOS in theater. At an orthopedic evaluation approximately a month after removal from theater, the CI reported persistent bilateral knee pain and left ankle pain. He reported increased bilateral knee pain with prolonged walking, weight bearing, running, jumping, marching and rucking. He reported resolution of his left ankle pain, but persistent swelling. There was intermittent pain at the lateral aspect of his left ankle and toe off with walking. The knee examination was significant bilaterally for full active ROM with crepitus (grinding sensation with knee motion), medial joint line tenderness and pain with patella compression. There was no evidence of knee instability. The ankle examination was significant for tenderness over the left anterolateral ankle.

The narrative summary (NARSUM) evaluation on 26 November 2003 noted reports of increased bilateral knee pain after prolonged walking and with weight bearing. The CI reported occasional swelling of the left ankle. He used Celebrex his joint pains. The knee and ankle examinations were consistent with the orthopedic examination. Radiographic evaluation showed left knee medial joint space narrowing, multiple loose bodies and moderate DJD. The right knee radiographs showed mild medial joint space narrowing. The ankle radiographs showed osteophytosis of the talus with slight osteoporosis. Diagnoses of bilateral knee DJD, left greater than right and left ankle pain were rendered.

At the VA Compensation and Pension exam (performed 5 months after separation), the CI reported chronic bilateral knee and left ankle pain with left ankle swelling. On physical examination an antalgic gait was noted with full knee flexion and extension bilaterally. There was no evidence of knee instability or swelling. There was left knee medial joint line tenderness. The ankle examination was significant for talar instability, tenderness to palpation over the insertion of the anterior talofibular ligament and full active ROM.

The Board directed attention to its rating recommendation based on the above evidence. The PEB adjudicated that degenerative arthritis of the knees as unfitting and combined the knee condition under a single disability rated at 10%; coded 5003 (degenerative arthritis). VA rated each knee separately at 10% coded 5010-5260; arthritis, due to trauma, substantiated by X-ray findings and painful motion. 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, if the PEB combined adjudication is not compliant with VASRD, each condition combined under the single disability rating must be reasonably justified as separately unfitting by the Board in order to remain eligible for rating. The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. The Board considered that there were multiple treatment notes documenting bilateral knee pain. Both knees were profiled and implicated in the commander’s statement. There was radiographic evidence of DJD and objective evidence of crepitus and tenderness in both knees. Members agreed the evidence supports the conclusion that the functional limitations of the each knee could be reasonably justified as separately unfitting. A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the treatment records and NARSUM provided satisfactory evidence for painful motion of both knees; thus, separate joint ratings are indicated IAW VASRD §4.71a and §4.59 (Painful Motion). 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 each knee for the DJD condition.

Contended Left Ankle Pain. The Board’s main charge is to assess the fairness of the PEB’s determination that the left ankle condition was not 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 left ankle pain was profiled and implicated in the commander’s statement, but was adjudicated as not unfitting by the PEB. The CI reported post-deployment resolution of his ankle pain with intermittent episodes of swelling. The preponderance of the evidence did not support that the left ankle pain, when separated from the knee pain, significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board majority concluded there was insufficient cause to recommend a change in the PEB fitness determination for the left ankle pain and no additional disability ratings are 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the degenerative arthritis of the knees condition, the Board unanimously agreed each knee was separately unfitting and recommends a disability rating of 10% for each knee, coded 5099-5003 IAW VASRD §4.71a. In the matter of the contended left ankle condition, the Board, by consensus, 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
Left Knee DJD 5099-5003 10%
Right Knee DJD 5099-5003 10%
COMBINED (w/ BLF) 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130926, 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, AR20150006979 (PD201301822)


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 of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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