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AF | PDBR | CY2013 | PD-2013-02074
Original file (PD-2013-02074.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02074
BRANCH OF SERVICE: Army          BOARD DATE: 20150804
SEPARATION DATE: 20050126


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 ( UH-60 Helicopter Repairer) medically separated for bilateral knee pain. The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “chronic patellofemoral syndrome [PFS]” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB (IPEB) adjudicated the bilateral knee pain condition, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) . The CI made no appeals and was medically separated.


CI CONTENTION: The applicant makes no specific contention in his application. His complete submission is at Exhibit A.


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

IPEB – Dated 20041208
 VA* - (~ 5 Yrs. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain of the Right and Left Knee… 5099-5003 10% Patellofemoral Syndrome w ith Plica Syndrome Claimed a s Left
 Knee		 5261-5260 10% 20100422
Patellofemoral Syndrome w ith Plica Syndrome, Claimed a s Right Knee 5260 10%
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 0 (equals SC, NSC & deferred)
RATING: 10%
 RATING: 20%
* Derived from original VA Rating Decision (VA RD ) dated 20 100709 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY: The Board noted that the earliest VA evaluation was nearly 5 years after separation. As elaborated above, the Board’s assessment must be derived from evidence that can be reasonably interpreted to reflect disability at the time of separation. Therefore the evidence from the Service record was assigned the determinant probative value with respect to the Board’s recommendation.

Bilateral Knee. The earliest entry for knee problems in the available service treatment record (STR) is from January 2004 (6 months after enlistment), and was directed at left knee pain. This initial examination of the left knee noted an antalgic gait, effusion, mild anterior laxity, and possible impingement (positive McMurray). These findings were not corroborated by any subsequent STR entries, and were contradicted in many of them. The CI was diagnosed with PFS (not a surgical indication) and did not respond adequately to conservative measures (physical therapy [PT] and steroid injections). The majority of the STR entries were directed at left knee complaints and treatment. An orthopedic entry from June 2004 (13 months prior to separation) suggests that it was directed at the right knee, although details were not elaborated. This described normal bilateral range-of-motion (ROM) for both knees; and, for the right knee, the absence of effusion, painful motion, instability, or signs of meniscal impingement (locking). These findings were duplicated in a follow-up entry. Bilateral knee X-rays were normal, as was magnetic resonance imaging of the left knee. Various STR entries for the left knee document grossly normal ROM (painful motion noted), stability to stress testing, negative signs of impingement and the absence of effusions. There was no documentation of any periods of incapacitation.

The narrative summary (NARSUM) was conducted 1 October 2004 (10 months prior to separation), and documented “recurring bilateral knee pain ... left knee is predominantly painful.” The only limitation elaborated was “unable to pass the running event ... required for graduation purposes.” The NARSUM physical examination recorded tenderness, but the absence of effusion, instability, or signs of meniscal impingement. The NARSUM measured ROM was bilateral flexion to 140 degrees (normal, minimum compensable 45). Formal ROM measurements for the MEB were conducted by PT 4 days after the NARSUM; and, recorded bilateral flexion to 125 degrees, left knee extension to minus 1 degree (normal 0, minimum compensable is minus 10), and right knee extension to minus 4 degrees; explicitly documenting painful motion. The L3 profile was for the left knee only. The commander’s statement did not clarify whether it referred to bilateral knee impairment.

As noted above, the post-separation VA Compensation and Pension (C&P) examination was too remote to be of significant probative value; but, did not contain any evidence of compensable ROM limitation or other findings which would alter a recommendation based solely on Service evidence.

The Board directed attention to its rating recommendation based on the above evidence. The PEB’s bilateral 10% rating analogous to 5003 (degenerative arthritis) was compliant with VASRD §4.71a criteria under 5003 for two or more major joints. The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each Service disability rating. The evidence makes clear that the left knee was associated with significantly more disability than the right in this case. The disparity was such that the question is raised of whether the right knee was reasonably justified as separately unfitting. The record indicates that primarily the left knee was the focus of treatment and reason for limitations and restrictions, and only the left knee was profiled. After due deliberation, members agreed that there was insufficient performance based evidence to support a conclusion that the functional impairment attributable only to the right knee would have rendered the CI unable to accommodate the physical requirements of his MOS or continue military service; and, accordingly cannot recommend a separate Service rating for it.
Having so concluded, the Board turned to deliberation of the appropriate coding and rating recommendation for the unfitting left knee condition. There was no compensable ROM impairment, instability, locking, or frequent effusions which would achieve a rating higher than 10%; and, members agreed that painful motion was adequately supported to achieve the minimum compensable rating of 10%. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the left knee; proposing code 5024 (tenosynovitis) based on its clinical compatibility.


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 Service-combined bilateral knee condition, the Board unanimously recommends a rating of 10% for an unfitting left knee condition coded 5024 IAW VASRD §4.71a; but, unanimously agrees the right knee condition was not reasonably justified as separately unfitting and thereby not subject to Service disability rating. 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:

CONDITION
 VASRD CODE RATING
Petellofemoral Syndrome, Left Knee 5024 10%
Petellofemoral Syndrome, Right Knee Not Unfitting
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131024, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record









                 
XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXXXXXXX, AR20150015450 (PD201302074)
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 description without modification of the combined rating or 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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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