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AF | PDBR | CY2013 | PD2013 01555
Original file (PD2013 01555.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1301555
BRANCH OF SERVICE: Army  BOARD DATE: 20140805
SEPARATION DATE: 20040820


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (31E/Internment/Resettlement Specialist) medically separated for bilateral patellar tendinitis. The CI’s bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P3/L3 and referred for a Medical Evaluation Board (MEB). The bilateral knee condition, characterized as “patellar tendonitis (tendinopathy)” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded reflex sympathetic dystrophy for PEB adjudication. The PEB adjudicated “bilateral patellar tendinitis…rated as tenosynovitis” as unfitting, rated 0% with likely application of the VA Schedule for Rating Disabilities (VASRD). The remaining condition w as determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “Soldier was only reviewed for bilateral patella femoral and no other issues i.e. sleep apnea, social anxiety, migraines, etc.”


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 applicant. The ratings for conditions meeting the above criteria are addressed below. In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process. The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference. The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON :

Service IPEB – Dated 20040615
 VA – (Based on Exam ~4 Years Post Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Patellar Tendinitis 5024 0% Patellofemoral Syndrome, Right 5260 10% 20080613
Patellofemoral Syndrome, Left 5260 10% 20080613
Reflex Sympathetic Dystrophy Not Unfitting No VA Entry
Other x 0 (Not in Scope)
 Specific Phobia, Situational Type 9403 30%** 20100323
Sleep Disorder 6847 50%** 20100323
Other x 0
Combined: 0%
 Combined: 20%*
* Derived from VA RD Dated 15 July 2008
** VA added Sleep Disorder (6847 at 50%) effective January 2008 and Specific Phobia (9403 at 30%) effective July 2009, both based on exam of March 2010 (combined 70%) .
ANALYSIS SUMMARY:

Bilateral Patellar Tendinitis. In 2003, the CI presented with an intermittent history of bilateral knee pain for 2 years considered medial bursitis of the left knee and right patellar tendinitis. A note dated 15 December 2003 indicated chronic bilateral knee pain for 4-5 years with pain accentuated by stress activities. He denied “any accident or incident that could have precipitated this reaction.” Orthopedic consultation on 19 December 2003 noted that the left knee pain was greater than the right especially when he ran, jumped, climbed stairs or squatted. There was no history of swelling, locking or periodic buckling. Other than tenderness to palpation bilaterally, the remainder of the examination was within normal limits. X-rays showed bilateral lateral patellar tilt indicative of a tracking problem. Physical therapy (PT) was initiated “to work on the patellar tendonitis as well as quad strengthening.” PT follow-up on 12 January 2004 noted ambulation with normal gait, full range-of-motion (ROM) with pain at the end range of flexion and tenderness to palpation globally around both knees. The CI had pain with the patellar apprehension test and ligament pain. In a follow-up PT visit on 6 February 2004, he was noted to still have “bilateral knee pain with RPPS (retropatellar pain syndrome) in nature.” Magnetic resonance imaging views of the left and right knees were negative on 6 February 2004. As he was getting worse with treatment, he was given an injection to the left knee, with 50% relief and was prescribed another non-steroidal anti-inflammatory medication for his chronic knee pain described as “almost RSD (reflex sympathetic dystrophy) like.” Referral for pain modulation was instituted and gabapentin (for nerve pain) was added and the anti-inflammatory medication was changed. The MEB physical examination narrative summary (NARSUM) dated 26 May 2004 noted, “although the pain was slightly controlled, he was unable to perform his job in his MOS. . . [and] his pain was. . . consistent with complex regional pain syndrome being that he had pain just with light touch. He would have pain at night when sheets would touch his legs at time. He intermittently had some heat and cold intolerance to his knees.” He had exquisite tenderness on both knees with pain of the kneecaps with the patellar grind test. He had no meniscal signs or ligamentous instability. He had a decreased popliteal angle with pain and could maintain full knee extension and knee flexion with pain. Rheumatologic laboratory workup was normal. His profile was P3, L3 with restrictions of no running or jumping and he was unable to do his combat related skills or to carry a rucksack. The MEB was initiated for bilateral knee pain since the CI maximized medical therapy and there was no surgical option.

The VA Compensation and Pension (C&P) examination in June 2008, approximately 4 years after separation, documented complaints of pain and weakness of both knees, with giving out 1-2 times a week while going down stairs. Gait was antalgic. There was crepitus and painful motion bilaterally with right knee flexion to 95 degrees and left knee flexion to 85 degrees (normal 140 degrees), both knees with normal extension.

The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the bilateral patellar tendinitis conditions under a single disability rating, coded analogously to 5024. Although VASRD §4.71a allows separate ratings for separately compensable joints, the Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication appeared to be not compliant, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for service 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. In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and both were profiled. Members agreed therefore that each knee should be conceded as separately unfitting and, that coding and rating features were essentially identical.
The PT and MEB exams both documented painful motion and patellar signs with the NARSUM documenting patellar grind. IAW VASRD §4.59 (painful motion), each knee is therefore entitled to at least the minimum compensable rating for each knee. The I nformal PEB found the condition of r eflex s ympathetic d ystrophy to be not unfitting . E vidence to support it to be independently unfitting was limited (“almost RSD [ reflex sympathetic dystrophy – a nerve-type condition ] like” or “consistent with complex regional pain syndrome”) even though the CI was prescribed a trial of low dose gabapentin 300mg daily. The Board considered that the pain symptoms of the knee areas was considered under the painful motion rating for each knee and there was not a preponderance of the evidence that RSD was separately unfitting or separately ratable with consideration of VASRD §4.14 (avoidance of pyramiding). 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 left knee patellar tendinitis and pain and 10% for the right knee patellar tendinitis and pain condition.

Social Anxiety/MH Condition. The CI’s application included “social anxiety” as a specific MH issue for contention. The Board’s main charge is to assess if any MH condition should have been found unfitting and ratable by the Service. Neither the MEB nor PEB listed any MH condition or diagnosis. The Board’s threshold for adding additional unfitting MH conditions 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 MEB physical, DD Form 2808, dated 4 May 2004 documented an exam finding of “slight anxiety” with a recommended profile of S1 and the summary of diagnoses and defects listed anxiety disorder. The DD Form 2807-1 (History), dated 26 April 2004, indicated positive responses to nervous trouble of any sort (occasional agoraphobia-no workup), received counseling of any type (about previous marriage [?]) and depression or excessive worry (apprehensive about future secondary to pain from pain in knee). No other service treatment records addressed the CI’s MH.

The contended social anxiety (or any MH diagnosis) condition was not permanently profiled or implicated in the commander’s statement, which stated the CI “has always been professional on and off duty and [was] . . . not facing any adverse action.” His NCO Evaluation Reports in 2002 and 2003 indicated the CI was among the best in regard to overall potential for promotion and/or service in positions of greater responsibility and in 2004, he was rated as fully capable. Permanent profile dated 26 May 2006 was S1 and did not list any duty restrictions referable to a MH condition. There was no VA MH exam proximate to separation. The first VA C&P was in March 2010. The CI had been employed for 4 years and was diagnosed with sleep apnea and “Specific Phobia, Situational Type” with a Global Assessment of Functioning of 65 (in the mild symptom range).

The Board considered the appropriateness of changes in MH diagnoses and fitness determination. At the time of processing through the military disability evaluation system, the DD Form 2808 MH diagnosis of anxiety disorder was not addressed by the NARSUM or considered by the MEB or PEB. Therefore, the Terms of Reference of the MH Review Project were met. The record did not contain sufficient evidence to support or refute the MH diagnoses noted in the record (anxiety disorder, social anxiety or major depression) at the time of separation. There was insufficient performance based evidence from the record that social anxiety, or any other MH condition regardless of diagnosis, significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient evidence that any MH condition rose to the level of being unfitting, and so no additional disability rating is 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. As discussed above, PEB reliance on the military service policy for rating bilateral knee tendinitis was likely operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the bilateral knee tendinitis condition, the Board unanimously recommends that each knee be found unfitting and separately rated; right knee with a disability rating of 10% coded 5099-5024, left knee at 10% coded 5099-5024, both IAW VASRD §4.71a. In the matter of the contended social anxiety (MH condition), the Board unanimously recommends a finding of not unfitting and no additional 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:

UNFITTING CONDITION
 VASRD CODE RATING
Bilateral Patellar Tendinitis Right Knee 5099-5024 10%
Left Knee 5099-5024 10%
COMBINED (w/ BLF)
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130917, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                          
XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX, AR20140017528 (PD201301555)

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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

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