RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00862
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Vehicle and Vehicular Equipment Maintenance Journeyman, medically separated for bilateral “patellofemoral chondromalacia and early patellofemoral osteoarthritis [bilateral]” with a disability rating of 10%.  

CI CONTENTION:  The applicant contends that the rating for his “bilateral knee issues” should be changed and that his major depression and major anxiety should be rated (not adjudicated by MEB or PEB).  The CI’s 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 Physical Evaluation Board (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 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 - 20080314	VARD - 20090209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Chondromalacia and Early Patellofemoral Osteoarthritis [Bilateral]	5099-5003	10%	Chondromalacia of the Left Knee with Scar 	5257	10%	20090121	
			Chondromalacia of the Right Knee with Scar 	5257	10%	20090121	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Patellofemoral Chondromalacia and Early Patellofemoral Osteoarthritis.  The PEB combined the right and left knee conditions under a single Service disability rating, coded analogously to 5003 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 “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 DES 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.  

According to service treatment records and the Medical Evaluation Board (MEB) narrative summary, the CI underwent three knee surgeries:  left knee surgery on 19 May 2006 for knee realignment and patella chondroplasty (smoothing of cartilage); right knee surgery on 1 December 2006 to realign the kneecap; and a second left knee surgery on 23 August 2007 to realign the kneecap and remove the hardware from the first surgery.  The CI had orthopedic exams in October, November and December 2007 which indicated continued bilateral knee pain, with positive patellar grind and slightly limited passive knee motion of each knee.  Following recovery from knee surgeries, the CI experienced persistent duty limiting pain in both knees and was referred for an MEB.  

At the NARSUM examination on 4 January 2008, 5 months before separation and 4 months after surgery, the physical examination showed bilateral limited passive ROM.  Active ROM was not reported.  The CI had bilateral genu valgum; positive bilateral patellofemoral grind tests with bilateral patellofemoral tenderness to palpation; and bilateral anterolateral rotary instability with no lateral pivot shift.  He had limited patellar mobility on the left knee when compared with the right.  Tests for ligamentous instability and meniscal damage were negative bilaterally.  The NARSUM diagnoses was “Patellofemoral chondromalacia/early patellofemoral osteoarthritis and obesity.”  The prognosis was that the CI had “significant disability in both knees as a result of patellofemoral cartilage injury … (and was) unlikely to recover the ability to perform …”

At the VA Compensation and Pension (C&P) examination on 21 January 2009, performed 8 months after separation, the examiner recorded that the CI walked “with a crutch and knee braces on both knees.”  Physical exam showed bilateral limited motion as indicated in the chart above with pain throughout all motions.  Pain increased with repetition and the examiner estimated that the increased pain caused an additional 10 degrees of ROM loss bilaterally.  The CI had bilateral tenderness along the medial joint line, significant bilateral crepitus, and positive bilateral McMurray’s tests (indicative of meniscal damage).  Tests for knee instability were negative bilaterally.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee conditions together at 10% coded analogously to 5003 (degenerative arthritis).  The VA rated each knee at 10% under the 5257 code (knee, other impairment of: recurrent subluxation or lateral instability) citing slight instability, limited leg flexion, limited leg extension, or pain on motion.  The Board first considered if each knee was separately unfitting as discussed above.  The commander’s statement and other STR evidence did not provide any information which would permit the Board to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with duty performance, members agreed that each knee was reasonably justified as separately unfitting.  

The Board adjudged that the VA exam had the highest probative value for rating at separation as it provided the most comprehensive ROM evaluation (active ROM) and included DeLuca assessment following repetitive motion.  Board members considered that the objective findings and associated disability for each knee were essentially identical, and agreed with the VA that the respective ratings should therefore be the same.  The Board concluded that there was sufficient evidence of painful motion and functional loss to support a 10% rating for each knee IAW §4.59 and §4.40.  The VA exam documented pain limited motion and positive meniscal signs, without evidence of instability and the Board adjudged that analogous coding to 5003 was predominate.  In considering routes to a higher rating however, there was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  Alternate rating under an analogous meniscal code of 5259 would include painful motion and would not offer any benefit to the CI.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was insufficient evidence for dual rating of either knee.  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 right knee condition, coded 5099-5003, and 10% for the left knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral knee conditions, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Patellofemoral Chondromalacia and Early Patellofemoral Osteoarthritis 	Right	5099-5003	10%	
	Left	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00862.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR