RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	 	CASE:  PD-2014-00476
BRANCH OF SERVICE:  AIR FORCE	 SEPARATION DATE:  20070716

SUMMARY OF CASE:  The available evidence of record reflects that this covered individual (CI) was an active duty, E4, Aerospace Propulsion Journeyman, medically separated for bilateral patellofemoral syndrome, rated at 10%.   

CI CONTENTION:  The CI contends that the PEB only rated him for his right knee and not both knees.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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 PEB – Dated 20070509	VARD- 20100716	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome	5099-5003	10%	Patellofemoral Syndrome, Right Knee	5299-5261	10%	20100629	
			Patellofemoral Syndrome, Left Knee	5299-5261	10%	20100629	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  According to STR and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain developed gradually in 2005, without specific injury or trauma.  Bilateral knee X-rays were unremarkable.  At multiple primary care visits in the STR the CI reported bilateral knee pain, right greater than left with and episodes of the right knee locking and “giving out,” making it difficult to walk, sit or stand for long periods of time.  Serial exams noted swelling, discoloration, and tenderness of the anterior and lateral aspects of the knees, without evidence of instability or meniscal pathology.  Some primary care and physical therapy evaluations addressed only the right knee.  There was normal motion of the right knee noted at a primary care evaluation on 11 July 2005, with a positive patellar grind test and no evidence of instability or meniscal pathology.  The CI was diagnosed with patellofemoral syndrome.  Magnetic resonance imaging of the right knee performed on 2 August 2005 noted a cyst at the base of the anterior cruciate ligament.  

The CI was referred to orthopedics for evaluation of the anterior cruciate ligament cyst on 30 January 2006 and the examination, which addressed only the right knee, diagnosed patellar tendonitis and confirmed the diagnoses of patellofemoral syndrome.  Computed tomography of the bilateral knees performed to evaluate patellar tracking was normal bilaterally.  No surgery was recommended at the time.  The CI was treated with PT, elastic knee bracing, and medications.

At an orthopedic evaluation for both knees on 5 January 2007, the CI reported some improvement in his right knee pain with less frequent episodes of pain and occasional giving way and rare buckling.  He denied feeling joint or kneecap instability.  The examination of the right knee showed TTP of the patella without swelling or crepitus.  There was no evidence of instability or meniscal pathology.  Right knee ROM was 0-105 degrees (normal 0-140), with painful motion.  The left knee examination showed no swelling, or evidence of instability or meniscal pathology.  Left knee ROM was 0 to 115 degrees, without painful motion.  The diagnosis remained PFS and there was no surgical indication.  Despite treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.  The permanent profile dated 19 March 2007 and the commander’s statement dated 29 March 2007 both noted physical limitations attributable to both knees.  

At a primary care MEB evaluation on 1 March 2007, the CI reported swelling of both knees with activity and continued intermittent right knee locking.  The examination showed a normal gait and stance.  Examination of the right knee showed TTP of the patellofemoral region, patellar tendon, and the joint lines, without swelling.  There was full ROM.  There was no evidence of instability or meniscal pathology.  A primary care follow-up for profile update on 19 March 2007 noted the CI walked with a limp and despite all treatment he was still unable to perform his duties.  At the MEB NARSUM was written on 1 March 2007 following the MEB evaluation noted above.  The NARSUM noted bilateral degenerative patellofemoral syndrome.  The NARSUM examiner summarized the findings (above) and stated that the CI continued to have difficulty with the physical activities required of his job on the flight-line.  The CI had been evaluated extensively by orthopedics and had undergone 9 months of physical therapy yet and maintained a poor prognosis given his current occupational exposures.  

At the VA Compensation and Pension (C&P) examination on 29 June 2010, performed 3 years after separation, the CI reported progressively worsening bilateral knee pain.  He reported intermittent use of a right knee brace.  The CI responded yes to bilateral symptoms of giving way, instability and pain, but denied episodes of dislocation, subluxation, or locking.  He reported flare-ups every 2 to 3 weeks that lasted 1 to 2 days.  Functionally, the CI reported he could stand for more than an hour but less than 3 and walk 1-3 miles.  The examination showed a normal gait.  There was tenderness, crepitus and snapping of both knees noted.  Right knee ROM was 0 to 124 degrees and left knee ROM was 0 to 116 degrees.  There was no objective evidence of pain on motion or additional loss of ROM with repetition of either the left or right knee.  

The Board first considered if each of the knee conditions, having been de-coupled from the bilateral knee PEB adjudication, remained separately unfitting as established above.  The STR available reflects bilateral knee pain throughout the record, but often noting that the CI’s right knee pain was greater than the left.  Neither the commander’s statement nor the physical profile mentioned either the right or left knee to be worse than the other.  The MEB NARSUM examiner (1 March 2007) recorded some clinical differences between the right and left knees that demonstrated that the right knee was worse than the left, but recommended that bilateral PFS impacted the CI’s ability to perform his duties.  The Board concluded that there was not a preponderance of evidence that overcame the Board’s presumption that each knee condition was reasonably considered separately unfitting at the time of separation.  The Board noted that the coding and rating features for both knees were essentially the same and therefore considered its rating recommendation for the unfitting knee conditions together below at the time of separation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10% coded analogously 5099-5003 (degenerative arthritis), for painful motion. The VA rated both the right and left knees 10% coded analogously 5299-5261 (leg limitation of extension), citing crepitus and tenderness and VASRD 4.59.  The Board noted that the VA C&P evidence is outside the 12-month period for special consideration of post-separation VA evidence IAW DoDI 6040.44, and the C&P exams are considered only to the degree that they provide information that reflects the CI’s condition proximate to the date of separation.  In this case the Board judged that the C&P examination did not provide probative evidence for its rating of the knee conditions at the time of separation.  Therefore, the Board relied upon examinations in the STR proximate to separation cited above, especially the orthopedic examination in January 2007 and the MEB NARSUM (which referenced the orthopedic consultations and primary care exams), for its rating recommendations.

The Board agreed that the bilateral knees could be rated 10% together, coded as 5099-5003 for the PFS of two major joints.  The Board next considered if the evidence supports separate VARSD ratings for the separately unfitting joints.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension.  There was evidence of painful motion of the right knee meeting a 10% rating coded as 5299-5261 (analogous to limited extension), an analogous code for PFS.  However there was no crepitus or painful motion of the left knee noted at the orthopedic evaluation and the primary care evaluation in March 2007 only included examination of the right knee.  Therefore the Board determined that if rated separately the evidence supports a 0% rating of the left knee.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity, frequent locking with effusions or any indication of dislocated meniscus or loose body, or history of surgery to remove a meniscus to support a rating under the respective codes for either knee.  There was no evidence of fracture, non-union, or malunion of the femur or tibia of either knee to support consideration under the respective codes for knee impairment related to long bone conditions.  There is therefore no VASRD §4.71a route to a higher combined rating for the knee conditions than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

BOARD FINDINGS:  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.  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131224, 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

Dear XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00476.

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,

Attachment:
Record of Proceedings