RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX                                                                                   CASE:  PD-2014-00307
BRANCH OF SERVICE:  AIR FORCE                                                         SEPARATION DATE:  20071120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Communications-Computer Systems Operator Journeyman) medically separated for a bilateral knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The “chondromalacia of patella” condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “bilateral knee pains,” as unfitting, 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The IPEB also adjudicated a headache condition and determined that the condition was not unfitting and therefore not ratable.  The CI made no appeals and was medically separated.    

CI CONTENTION:  Her condition continues to worsen and negatively impact her daily activities.  Her 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 20070926	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Right Knee with Degenerative Joint Disease	5010	10%	20080324	
			Surgical Scar on Right Knee	7804	10%	20080324	
			Left Knee Pain	5260	NSC	20080324	
Headaches	Not Unfitting	Migraine Headaches	8100	0%	20080324	
Other x 0 (Not In Scope)	Other x 12 	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080730 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  The PEB combined the right and left knee conditions as a single unfitting condition coded analogously to 5003 (degenerative arthritis) and rated 10%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board also noted that the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the Disability Evaluation System or be found unfit because of physical disability. When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the knee conditions is presented together below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Bilateral Knee Pain Condition.  According to service treatment records and the narrative summary (NARSUM) the CI had a history of bilateral retropatellar pain (behind the kneecap), first documented in July 2005.  At an orthopedic evaluation 15 November 2006, the CI reported right knee pain for 2 years that had not improved with physical therapy.  The exam noted right knee range-of-motion (ROM) of extension-flexion of 0-135 degrees (normal 140), with crepitus and a positive patellar grind.  There was no swelling and the knee was stable.  Right knee X-rays noted degenerative changes of the patellofemoral joint.  The majority of treatment notes in record addressed the right knee, but the first note that addressed the knees in record noted bilateral knee pain.  A computed tomography patellar tracking study 8 December 2006 showed bilateral mal-alignment and mal-tracking.  The CI underwent right knee arthroscopy for patellar release, with removal of a small piece of the tibia (osteotomy) and repair of patellar cartilage 26 March 2007.  Following the surgery there was initial improvement, but at an orthopedic follow-up evaluation 21 August 2007, the CI reported continued right knee symptoms.  The exam noted knee ROM of 0-120 degrees.  There was no joint line tenderness or effusion and the knee was stable.  The examiner noted that X-rays indicated the tibial osteotomy was healed and the surgical hardware was intact.  According to the NARSUM, the CI continued to have left knee pain, but was not going to have surgery.    

The NARSUM noted that the CI had been on recurrent profiles for bilateral knee pain.  Temporary profiles from July 2005 to separation listed physical restrictions that would equally shield one or both knees, and the final profile in record noted the CI was not cleared for deployment or physical training, but could exercise at her own pace, wear tennis shoes and walk with crutches.  The commander’s statement indicated that the CI’s condition did not impact her duty performance and that her current profile restrictions “do not impair her ability to fully execute her assigned duties here or at any worldwide location.”  The PEB remarks on Air Force Form 365 noted that knee pain caused duty restrictions of “may wear tennis shoes, may walk with crutches,” were unfitting.  At the MEB exam 6 July 2007, 5 months before separation, the CI reported chronic bilateral patellofemoral syndrome (PFS).  The MEB physical exam noted only that lower extremity (LE) strength was 5/5 and there was no swelling.

At the VA Compensation and Pension (C&P) exam 24 March 2008, 4 months after separation, the CI reported bilateral knee pain and swelling, constant right knee pain and left knee pain “with over use.”  She reported regular use of a right knee brace and use of a left knee brace with sustained exertion, but no use of a cane or crutches was noted.  The exam noted normal posture and gait.  The right knee was swollen and there was tenderness to palpation of the patella.  There was a scar over the anterior patella that was tender, but not adherent.  There was crepitus with ROM of both knees.  Right knee ROM was 0-130, with painful motion and left knee ROM was 0-140, without painful motion.  Strength, sensation, and reflexes of the bilateral LEs were normal.  There was no laxity noted of either joint.  Left knee X-rays were normal and right knee X-rays showed post-operative findings and DJD.

The Board first considered if the evidence supports that each knee having been de-coupled from the PEB’s combined adjudication remained unfitting as established above.  The evidence in the STR supported that the CI initially sought treatment for bilateral knee pain, and she was given recurrent profiles for bilateral knee pain.  Treatment was primarily undertaken for the right knee, and following surgery, the CI reported continued right knee pain and at the MEB exam, she reported left knee pain but was not going to have surgery.  Though the commander indicated that neither knee impaired the CI’s ability to perform her assigned duties, the PEB determined that the profile limitations of alternate footwear and use of crutches were unfitting, which seemed to the Board to apply to both knee conditions, though, as documented in STR, the right knee seemed to be worse than the left.  Members concluded that there was not a preponderance of evidence in record to overcome the presumption that each knee was reasonably considered unfitting at the time of separation and therefore eligible for individual Service rating.

The Board next directed its attention to its rating recommendation based on the above evidence.  The Board addressed the rating of the right knee first and agreed that the evidence supports a 10% rating, coded according to 5003 rating criteria, based upon evidence of degenerative changes with satisfactory evidence of painful motion or coded as 5299-5261 (analogous to limited leg extension), an analogous code for PFS/retropatellar pain syndrome IAW VASRD §4.20 (Analogous ratings) based on painful limited motion IAW VASRD §4.59 (painful motion.  The Board reviewed to see if a higher evaluation was supported with any other applicable code, but 10% is the highest rating under 5003 for a single joint.  The Board considered coding analogous to impairment of the tibia (status post restructure of the tibia) and noted the criteria are subjective with 10% for “mild,” 20% for “moderate” and 30% for “marked” knee disability and agreed that the normal gait at the C&P exam supports rating the knee disability as “mild” and not “moderate.”  Additionally, there was no evidence of knee instability, cartilage injury or removal, knee ankylosis, or sufficient limitation of ROM to support a higher rating.  

The Board next considered a rating for the left knee, with consideration of all coding and rating approaches as elaborated for the right knee.  The MEB exam did not provide objective findings for either knee and orthopedic exams in the year before separation addressed the exam of the right knee only.  At the C&P exam, the left knee was noted to be normal with full and painless ROM and no laxity and X-rays did not demonstrate any degenerative changes.  Therefore, the evidence supports a 0% rating for the left knee coded as 5003 or 5299-5261.  The Board noted that both knees combined as a bilateral knee condition and coded according to 5003 could be rated 10% based upon the CT findings of patellofemoral pathology of both knees for PFS, which can also be coded analogously to 5003 IAW §4.20.  Also, as noted for the right knee, the evidence does not support a higher rating for the left knee with any other applicable code.  Thus, the Board determined that although each knee was recommended as unfitting during deliberations, no higher than a combined 10% rating could be achieved for the knee conditions, whether rated as a bilateral condition or rated individually.  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the bilateral knee condition.  

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 condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00307.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

								XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings