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AF | PDBR | CY2013 | PD-2013-02551
Original file (PD-2013-02551.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02551
BRANCH OF SERVICE: Army  BOARD DATE: 20150120
SEPARATION DATE: 20050316


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Military Police) medically separated for a chronic bilateral knee pain condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The bilateral knee condition 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 0%, IAW the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “My knee issues caused back issues and the stress of not being able to continue with my service cause incredible amounts of stress that lead to an ulcer which I have issues with still.”


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 :

Service IPEB – Dated 20050201
 VA – (1 Day Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Knee Pain 5099-5003 0% Patellofemoral Syndrome Left Knee 5099-5014 10% 20050317
Patellofemoral Syndrome Right Knee 5099-5014 10% 20050317
Other x 0 (Not in Scope)
 Other x 2
Combined: 0%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 20050520 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Board noted the left and right knees were examined and treated together in the record. The Board will discuss these conditions together to avoid clerical repetition and then separate them for rating considerations.

Chronic Bilateral Knee Pain. The narrative summary (NARSUM), 2 months prior to separation stated that the CI had bilateral knee pain (diagnosed as retropatellar syndrome) for over 3 years. The record indicated the CI had twisted his left knee in 2002 and eventually his right knee started hurting. The pain was retropatellar with swelling and giving way and would “drop [him] to the ground occasionally due to pain.” The NARSUM exam showed “full active range of motion (ROM),” negative varus/valgus in stability, negative effusion, and negative Lachman’s. He had “positive patellofemoral compression [pain with flexion of the knee while pushing on the kneecap] and positive medial facet tenderness.” Left knee X-ray showed an osteophyte off the inferior patella. At two separate visits, approximately 6-to-7 months prior to separation, examinations documented positive patellar grind. At the MEB exam, the CI reported having had “swelling in both knees and they have given out on me.” The MEB physical exam was “normal.” At the VA Compensation and Pension exam performed a day after separation, the CI reported daily constant bilateral knee pain. He wore braces on both knees and had had no incapacitating episodes in the last 12 months. The examiner documented a normal gait without limp, but the CI was wearing bilateral knee braces. He had crepitus in both knees. The CI had left knee ROM 0-140 degrees (normal) with pain starting at 90-140 degrees. He had pain in both knees on exam and with deep knee bends and standing on his toes. There was no change on repetition and there was no swelling, effusion, muscle spasm, joint laxity, or muscle atrophy.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral knee pain condition at 0% analogous to VASRD code 5099-5003 (degenerative joint disease). The Board first considered if the left knee and right knee conditions, having been de-coupled from the combined PEB adjudication, remained individually unfitting. In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled. Members agreed therefore that each knee should be conceded as separately unfitting; and, that coding and rating features were logically identical. The VA rated each knee 10% using code 5099-5014 (osteoarthritis) for a combined rating of 20%. There was no evidence that ROM limitations met the compensable threshold in either knee under the specific knee codes. The crux of the Board discussion was if there was sufficient evidence of painful motion IAW VASRD §4.59 [including §4.40 (functional loss) and §4.45 (the joints)] to warrant minimal compensable ratings for each knee. The Board considered that positive patellar compression testing is painful motion as it is pain around the kneecap when moving the knee joint. VA exam also documented crepitus (which is specified in §4.59) as well as painful motion. Treatment records and the diagnosis of “patellofemoral syndrome” also indicated bilateral knee pain with use. The Board agreed that there was sufficient evidence to reasonably concede painful motion.

The Board agreed the evidence did not meet the minimal ROM limitations for rating under VASRD codes 5260, (limitation of flexion), or 5261, (limitation of extension), and that no rating higher than 10% was supported under code 5262, (knee impairment). The Board unanimously agreed the neither the right knee nor left knee condition rose to the level of “moderate severity” required for a single joint 20% rating. There was no evidence of ligamentous laxity, frequent effusions, meniscal pathology, or locking (or any indication of loose body) to warrant either a 20% rating or dual coding of either knee. There is therefore no VASRD §4.71a route to a rating higher than 10% under any applicable code, and no grounds for additional rating of instability. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.59 (painful motion), the Board recommends that each knee be found unfitting and each knee rated at 10% coded as 5099-5014 (chondromalacia patella analogous to osteomalacia).
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 bilateral knee pain condition, the Board unanimously recommends that each knee be separately rated as follows: an unfitting right knee condition coded 5099-5014 and rated 10% and an unfitting left knee condition, coded 5099-5014 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 Syndrome Left Knee 5099-5014 10%
Patellofemoral Syndrome Right Knee 5099-5014 10%
COMBINED (w/ BLF) 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131115, 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 XXXXXXXXXXXXXXX, AR20150010430 (PD201302551)


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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