RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04355
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20070917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Communication-Computers System Control Craftsman, medically separated for “bilateral knee pain due to patellofemoral syndrome status post left knee partial meniscectomy” with a disability rating of 10%.

CI CONTENTION:  His left knee and TMJ 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 based upon a 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 - 20070702	VARD - 20130918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain due to Patellofemoral Syndrome…	5099-5003	10%	Right Knee Patellofemoral Syndrome S/P Patella Fracture	5257	0%	20130816	
			Left Knee Patellofemoral Syndrome S/P Meniscectomy With Scar	5257	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

BILATERAL KNEE PAIN:  The PEB combined the right knee and left knee conditions as a single unfitting condition coded 5099-5003 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’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 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 right knee and left knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain began when he sustained a right patellar fracture in 2003 while deployed.  The CI experienced persistent duty limiting symptoms including chronic pain, giving out, and frequent locking and he was referred for an MEB.  A 22 February 2007 right knee MRI, 7 months prior to separation, was unremarkable except for a possible small bone contusion.  There was normal appearance of the menisci, ligaments, tendons, and cartilage with no effusion or degenerative changes.  A 23 February 2007 orthopedic evaluation, 6 months prior to separation, documented right knee range of motion (ROM) was full.  In the 22 May 2007 MEB NARSUM, 3 months prior to separation, the CI reported persistent knee pain with running, stooping and bending.  The MEB physical examination noted patellar grinding right greater than left and a negative McMurray’s (assesses menisci) test bilaterally.  There was no medial or lateral knee laxity or numbness and tingling into the legs or feet.  During the MEB examination (recorded on DD Form 2697) dated 3 August 2007, 1 month prior to separation, the CI reported bilateral knee pain.  The physical examination documented bilateral heel pain with a history of left knee meniscal tear and right patella fracture, along with patellofemoral syndrome (anterior knee pain symptom complex involving patella).

Left Knee Pain.  According to STR and the MEB NARSUM, the CI’s left knee pain condition began sometime in 2001 when he suffered a torn meniscus injury during a military training exercise.  The CI underwent a left meniscal repair (2001) followed by a left partial meniscectomy (2004).  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic bilateral knee pain” for PEB adjudication.  A 22 February 2007 left knee MRI, 7 months prior to separation, was unremarkable.  There was normal appearance of the menisci, ligaments, tendons, and cartilage with no effusion or degenerative changes.  A 23 February 2007 orthopedic evaluation, 6 months prior to separation, documented full left knee ROM.  During the MEB NARSUM, 3 months prior to separation, the CI reported persistent knee pain with running, stooping and bending.  He also noted that both knees frequently gave out with frequent locking of the left knee.  The MEB physical examination noted patellar grinding and a negative McMurray’s test bilaterally.  There was no medial or lateral knee laxity or numbness and tingling into the legs or feet.  During the MEB examination the CI reported bilateral knee pain.  The physical examination documented bilateral heel pain with a history of left knee meniscal tear, along with patellofemoral syndrome.

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right knee with the left knee condition and applied a single 10% rating, analogously coded 5003 code (degenerative arthritis).  The VA rated the bilateral patellofemoral syndrome 0% for each knee, coded 5257 (knee, other impairment) based on the VA C&P examination 6 years after separation, citing a diagnosed disability with no compensable symptoms for both knees.

The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board members concluded that the right knee condition would reasonably have caused the CI to be referred into the DES, or be found unfit.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  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.

The Board next considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board members concluded that the left knee condition would reasonably have caused the CI to be referred into the DES, or be found unfit.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was; however, evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  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 condition, coded 5259.

BOARD FINDINGS:  In the matter of the bilateral knee pain due to patellofemoral pain syndrome, 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 5259 and rated 10%, both IAW VASRD §4.71a.  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 Syndrome… Right Knee	5099-5003	10%	
Patellofemoral Syndrome… Left Knee	5259	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140923, 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 

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04355.

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