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AF | PDBR | CY2013 | PD-2013-01985
Original file (PD-2013-01985.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-01985
BRANCH OF SERVICE: Army  BOARD DATE: 20140807
SEPARATION DATE: 20050420


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (35F/Maintenance) medically separated for a bilateral knee condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but an alternate physical fitness test was authorized. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The chronic bilateral knee pain condition, characterized as “bilateral Osgood-Schlatter disease,” 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 secondary to Osgood-Schlatter disease” as unfitting, rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “I was determined to be unfit to continue my military service due to the injury/disease. This Osgood-Schlatter disease is a disease that has dramatically affected my day to day lifestyle. I have been going to the VA since 2005 and this condition has gotten any better.”


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 condition is addressed below and, 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. The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.


 RATING COMPARISON :

Service IPEB – Dated 20050224
 VA - Based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Knee Pain Secondary To Osgood-Schlatter Disease 5099-5003 0% Osgood-Schlatter Disease, Left Knee 5299-5260 10% STR
Osgood-Schlatter Disease, Right Knee 5299-5260 10% STR
Other Conditions in Scope x 0
 Other x 6
Combined: 0%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 20050526 ( most proximate to date of separation [ DOS ] ).
ANALYSIS SUMMARY: IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

Chronic Bilateral Knee Pain. The PEB combined the chronic right and left knee pain conditions under a single disability rating, coded analogously to 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. The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Review of the STR showed that the CI complained of gradual onset of bilateral knee pain beginning in April 2001. He was diagnosed with bilateral Osgood-Schlatter disease (micro-avulsions and tendinous inflammation from repetitive contraction of the patellar tendon insertion upon the tibial tubercle). The site of pain was on the front of the leg just below the knee cap. X-ray showed lack of fusion of the tibial tuberosity bilaterally. At an orthopedic surgery evaluation on 19 November 2004 (5 months prior to separation) the CI complained of 5/10 bilateral knee pain which was exacerbated by bending the knees. Physical examination showed bilateral prominent and tender tibial tubercles. The diagnosis was chronic bilateral Osgood-Schlatter disease, for which the CI declined surgical intervention. A physical therapy examination on 6 December 2004 (4.5 months prior to separation) showed prominent, tender tibial tuberosities. At the narrative summary (NARSUM) exam on 4 January 2005 (3.5 months prior to separation), the CI reported that his condition had worsened to the point that he could not complete the walk for the physical training test or walk 2 miles with combat gear. The physical examination was normal except for prominent tibial tuberosities that were tender. The diagnosis was listed as bilateral Osgood-Schlatter disease.

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

Knee ROM
(Degrees)		 Ortho ~5 Mos. Pre-Sep PT ~ 4.5 Mos. Pre-Sep
Left Right Left Right
Flexion (140 Normal) 125 125 130 130
Extension (0 Normal) 0 0 -3 -3
Comment +Tender +Tender +Tenderness, painful motion
§4.71a Rating 10%* 10%* 10%* 10%*
                       *With application of painful motion (§4.59)

The Board first considered whether the right knee condition and left knee condition, when considered independently, were each separately unfitting for continued military service and therefore warranted separate ratings. The STR showed that the CI complained of bilateral knee pain, the knees were treated equally and concurrently and that concordant knee examinations were present. During the course of evaluation and treatment, there was little distinction documented between the bilateral knees by the CI, examiners, imaging studies, or treatment interventions. The NARSUM and the MEB identified bilateral knee disease as medically unacceptable; and both knees were identified on the permanent profile. The Board unanimously agreed therefore, that the right and left knee conditions were reasonably justified as separately unfitting and that they met VASRD §4.71a criteria for separate ratings.

In assigning a 0% rating for the bilateral knee condition, the PEB noted the condition existed prior to service, but was subsequently aggravated by service and did not apply a deduction. The VA assigned a 10% rating for each knee (based on the STR) under an analogous 5260 code (leg, limitation of flexion of). Board members agreed there was no evidence of compensable limitation of motion, but concluded that there was sufficient evidence of painful motion to warrant a 10% rating for each knee IAW VASRD §4.59. There was no evidence of knee ankylosis, dislocated meniscus, or instability for rating consideration under the corresponding diagnostic codes (5256, 5258, and 5257 respectively). 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 right knee pain condition and 10% for the left knee pain condition, coded 5099-5003.


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 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 bilateral knee pain secondary to Osgood-Schlatter disease condition, the Board recommends that it be rated for two separate unfitting conditions as follows: chronic right knee pain condition coded 5099-5003 and rated 10%; and chronic left knee pain condition coded 5099-5003 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
Chronic Right Knee Pain Secondary to Osgood-Schlatter Disease 5099-5003 10%
Chronic Left Knee Pain Secondary to Osgood-Schlatter Disease 5099-5003 10%
COMBINED (w/ BLF) 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131029, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150002529 (PD201301985)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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