RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03323
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20081020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Culinary Specialist, medically separated for “chronic bilateral knee pain,” with a disability rating of 10%.  

CI CONTENTION:  “Please consider all conditions.”  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 - 20080610	VARD - 20090415	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5299-5003	10%	Medial Meniscal Injury with Patellofemoral Pain 
Syndrome, Left Knee	5257	0%	STR	
Bilateral Patellofemoral Pain Syndrome	Not Unfitting 
Cat II	Patellofemoral Pain Syndrome, RIGHT Knee	5257	0%	STR	
Left Medial Meniscal Injury S/P Arthroscopic
Repair	Not Unfitting 
Cat II	No VA Placement	
Allergic Rhinitis	Not Unfitting 
Cat III	Allergic Rhinitis	6522	NSC	
Atopic Eczematous	Not Unfitting 
Cat III	Eczema	7806	NSC	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the left and right knee conditions under a single service disability rating, coded analogously to 5003 and rated 10%.  The PEB also listed “bilateral patellofemoral pain syndrome and left medial meniscal injury status post arthroscopic repair” conditions as related diagnoses (Category II) contributing to the disability in this case.  The approach by the PEB not uncommonly reflected its judgment that the constellation of knee conditions was unfitting and there was no need for separate fitness adjudications.  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 whether 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.  The evidence for the bilateral knee pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the left knee condition began late 2005, while another source indicated a knee injury in February 2006 after playing basketball.  Magnetic resonance imaging (MRI) was consistent with injury to the medical collateral ligament with no disruption.    Orthopedic evaluation in August 2006 revealed the CI had a medial meniscal tear and he underwent surgery on 12 September 2006 and was continued on limited duty status.  At the time of the orthopedic follow-up appointment on 23 March 2007, the CI reported persistent pain.  On examination, there was patellar maltracking.  Continued physical therapy was recommended.  The orthopedic surgeon diagnosed the CI with bilateral patellofemoral pain syndrome in December 2007.  Despite treatment, the left knee pain could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic pain due to trauma, tear of medial cartilage or meniscus of knee (current), and chondromalacia of patella” for PEB adjudication.  

The MEB NARSUM examination on 26 February 2008, showed the CI had full range of motion (ROM) and strength of the left knee.  The examiner noted mild joint tenderness and patellar crepitus and recorded the CI’s medical condition prevented him from performing his duties.  The commander’s statement dated 28 April 2008 indicated, the CI was not worldwide assignable and was not able to participate in the physical readiness test (PRT), but had good potential for continued service in his present physical condition.  

The CI failed to report for his VA Compensation and Pension (C&P) examination scheduled on 12 December 2008 and therefore his rating decision was based on the evidence of record.  At the time of the VA clinic appointment on 05 March 2009, 5 months after separation, the CI reported persistent bilateral knee pain.  The examiner noted swelling and stiffness.  Radiographic imaging studies showed the knee joint and patellofemoral joint were preserved bilaterally.  There was no evidence of subchondral bone changes or spur formation.  The examiner noted that bilateral knee imaging series was “unremarkable.”  

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left knee condition with the right knee condition and applied a single 10% rating coded 5299-5003 (degenerative arthritis).  The VA rated the left knee condition 0% coded 5257 (knee, other impairment of), citing that a noncompensable evaluation was assigned because the evidence did not show recurrent subluxation or lateral instability of the knee which was “slight.”  The Board considered whether the left knee condition, when considered alone, separate from the right knee condition, was unfitting for continued military service.  The Board concluded that the unbundled left knee condition was reasonably justified by the record as separately unfitting.  The Board then considered its rating recommendation for the separately unfitting left knee condition at the time of separation.  Although the nature of the injury and the persistent pain and limitations in evidence are not inconsequential, the Board must cite reasonable supporting evidence linked to specific rating criteria in its recommendations.  The Board members agreed there was no evidence of painful motion with functional loss supporting a separate 10% rating (based on §4.59, §4.40 and §4.45).  Likewise there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no evidence of moderate knee disability or marked knee disability to support a 20% or 30% rating under the 5262 code (tibia and fibula, impairment of).  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), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  Finally, 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).  The Board determined that the Navy Category II conditions of bilateral patellofemoral pain syndrome and specifically the left knee patellofemoral pain syndrome and the  medial meniscal injury s/p arthroscopic repair were related to or contributed to the left knee pain and were not separately unfitting and therefore noncompensable.  As noted above, the bilateral diagnosis supported a single 5003 code based rating for “2 or more major joints” without compensable limitations or painful motion; thus there is VASRD §4.71a latitude for a bilateral rating.  All members agreed, therefore, that the evidence did not support recommending a separate left knee disability rating.  After due deliberation, considering all of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled left knee condition.  

Right Knee.  According to the STR and the MEB NARSUM, a note in August 2007 indicated the CI had right knee pain for about 2 months because the right knee was favored after surgery on the left knee; however, an earlier note with an unclear date indicated the CI had right knee pain after playing basketball.  On 09 September 2007, the CI was evaluated at the family practice clinic for persistent right knee pain symptoms.  The examiner noted tenderness along the medial joint line and a positive McMurray test (to determine a meniscal tear) and the CI was placed on limited duty.  Magnetic resonance imaging (MRI) on 19 September 2007 showed a possible “very small” tear of the medial meniscus.  At the time of the orthopedic follow-up appointment on 10 October 2007, the CI had reported persistent pain.  The examiner noted there was no tear of the lateral or medial meniscus.  The CI was treated conservatively and completed multiple courses of physical therapy.  An MRI of the right knee in January 2008, showed mild degeneration of the posterior horn of the medial meniscus without a definite tear identified.  The lateral meniscus was intact and there was no significant joint effusion.  Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chondromalacia of patella” for PEB adjudication.  

The MEB NARSUM examination dated 26 February 2008, noted the CI had full ROM and strength of the right knee as well as mild joint tenderness and patellar crepitus, which prevented him from performing his duties.  According to the commander’s statement dated 28 April 2008, the CI was not worldwide assignable and was not able to presently participate in the PRT, but had good potential for continued service in his present physical condition.  

The CI failed to report for his VA C&P examination scheduled on 12 December 2008 and therefore his rating decision was based on the evidence of record.  At VA clinic appointment on 5 March 2009, 5 months after separation, the CI reported persistent bilateral knee pain.  The examiner noted swelling and stiffness.  Radiographic imaging of the knees was unremarkable with the knee joint and patellofemoral joint were preserved bilaterally.  There was no evidence of subchondral bone changes or spur formation. 

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left knee condition with the right knee condition and applied a single 10% rating coded 5299-5003 (degenerative arthritis).  The VA rated the left knee condition 0% coded 5257 (knee, other impairment of), citing that a noncompensable evaluation was assigned because the evidence did not show recurrent subluxation or lateral instability of the knee which was “slight.”  The Board considered whether the right knee condition, when considered alone, separate from the left knee condition, was unfitting for continued military service.  The Board concluded that the unbundled right knee condition was reasonably supported by the record as separately unfitting.  The Board then considered its rating recommendation for the separately unfitting right knee condition at the time of separation.  Although the nature of the injury and the persistent pain and limitations in evidence are not inconsequential, the Board must cite reasonable supporting evidence linked to specific rating criteria in its recommendations.  The Board members agreed there was no evidence of painful motion with functional loss supporting a separate 10% rating (based on §4.59, §4.40 and §4.45).  Likewise there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no evidence of moderate knee disability or marked knee disability to support a 20% or 30% rating under the 5262 code (tibia and fibula, impairment of).  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), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  Finally, 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).  The Board determined that the Category II condition of bilateral patellofemoral pain syndrome and specifically the right knee patellofemoral pain syndrome was related to or contributed to the right knee pain and was not separately unfitting and therefore noncompensable.  As noted above, the bilateral diagnosis supported a single 5003 code based rating for “2 or more major joints” without compensable limitations or painful motion; thus there is VASRD §4.71a latitude for a bilateral rating.  All members agreed, therefore, that the evidence did not support recommending separate left and right knee disability ratings.  After due deliberation, considering all of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled right knee conditions.  

Contended PEB Conditions.  Atopic eczematous (dermatitis) and allergic rhinitis-related conditions.

Atopic Eczematous (Dermatitis).  The CI complained of a rash in patches over the body for 1½ year that was treated with antifungal and topical steroid cream.  The CI had asthma and eczema as a child.  The examiner noted circular patches consistent with nummular eczema and prescribed clobetasol ointment in December 2007.  In February 2008 the CI stated the medication worked great (80% improved) for a period of time, but the rash “eventually will come back.”  On examination the rash consisting of patches, which were predominately on the extremities, was much improved.  

Allergic Rhinitis.  The CI was seen in November 2007 for congestion with a post nasal drip and sinus pressure intermittently over the prior couple of weeks and had it multiple times the past.   The diagnosis of allergic rhinitis was made and treatment consisted with Deconamine SR (pseudoephedrine, a nasal decongestant and chlorpheniramine maleate, an antihistamine).   The record indicated that loratadine (a long acting antihistamine) was prescribed thereafter.  There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for atopic eczematous (dermatitis) and allergic rhinitis conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously or majority recommends no change in the PEB adjudication.  In the matter of the contended atopic eczematous (dermatitis) and allergic rhinitis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140529, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 8 Aug 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC

						 XXXXXXXXXXXXXXXXXXXX
	     				  	Assistant General Counsel
						(Manpower & Reserve Affairs)