RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00221
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070926

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cryptologic Maintenance Technician, medically separated for “bilateral patella femoral syndrome” with a disability rating of 10%.  

CI CONTENTION:  The applicant had multiple conditions that were not separately unfitting.  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 - 20070625	VARD - 20080528	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patella Femoral Syndrome	5099-5003	10%	Right Knee Patellofemoral Syndrome	5003-5260	10%	20071105	
			Left Knee Patellofemoral Syndrome	5003-5260	10%	20071105	
Chondromalacia Patellae
Bilaterally	Not Unfitting 
Cat III	No VA placement	
Abdominal Muscle Weakness	Not Unfitting 
Cat III	Abdominal Muscle Weakness	5319	0%	20071105	
Multiple Abdominal Surgeries Including Total
Hysterectomy	Not Unfitting 
Cat III	Hysterectomy, Complete	7617	50%	20071105	
Migraine Headaches	Not Unfitting 
Cat III	Migraines	8100	30%	20071105	
Pulmonary Nodule	Not Unfitting 
Cat III	No VA placement	
Pulmonary Embolism, Postpartum	Not Unfitting 
Cat III	Left Lung Blood Clot	6817	0%	20071105	
Chronic Chest Pain Syndrome	Not Unfitting 
Cat III	Chronic Chest Pain Syndrome	7099-7006	NSC	20071105	
Transient Alteration Of Awareness, Single
Episode…	Not Unfitting 
Cat III	No VA placement	
Obesity	Not Unfitting 
Cat IV	No VA placement	
COMBINED RATING:  10%	70%	

ANALYSIS SUMMARY:  

Bilateral Patella Femoral Syndrome.  The PEB combined the right 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.  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.  The evidence for both knee conditions are presented, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in November 2003 without any trauma.  In November 2004 at a sports medicine evaluation the CI reported bilateral knee pain worse with prolonged sitting, stairs, or running.  Physical examI was normal except for pain with patellar compression.  Bilateral knee magnetic resonance imaging in 2004 showed bilateral chondromalacia patella (CMP) and bilateral knee X-rays in 2006 showed degenerative arthritis of the right knee.  She was treated with activity modification, anti-inflammatory medications, and physical therapy without resolution of the symptoms.  The MEB forwarded “pain in joint involving lower leg” for PEB adjudication.  

There was no period of limited duty for the bilateral knee pain in record.  The Non-Medical Assessment (NMA) did not specifically note any medical condition, but indicated the CI was unable to pass physical readiness or fitness testing.  The JDETS noted the CI reported bilateral knee pain with stairs and that MRI noted patella cartilage damage bilaterally and X-rays showed arthritis of the right knee.  A notation on the JDETS dated 25 June 2007 indicated the CI was unfit and recommended separation related to 5099-5003 and 10% rating. 

The MEB NARSUM examination on 10 February 2007, 8 months prior to separation, the CI reported intermittent pain in the patellar region bilaterally and occasional locking of the left knee, aggravated by stair climbing.  Physical examination was performed of both knees and identical physical findings for the knees were reported.  There was tenderness to palpation of the patella, without effusion, crepitus, or abnormal tracking of the patella.  There was no evidence of instability or meniscal pathology.  A MEB addendum on 14 February 2007 noted the CI could perform limited squats with pain bilaterally.

The MEB examination (recorded on DD Forms 2807 and 2808) dated March 2007, 7 months prior to separation, noted complaints of bilateral knee pain and recent giving out of the left knee.  Physical examination noted no abnormalities of the lower extremities.  

At the 05 November 2007 VA Compensation and Pension (C&P) evaluation, 1 months after separation, both the General Medical and Joints examinations were performed at the same visit.  The CI reported intermittent rest pain with certain positions, with stiffness, locking, fatigability, lack of endurance, instability and giving way of both knees one to two times per week.  She reported the pain was aggravated by walking over two hours, one flight of stairs, bending and squatting.  The CI did not use an assistive device for ambulation.  There were no dislocations or subluxations reported.  The CI had not missed any work due to the condition in the last 12 months.  Physical examination showed a normal gait.  There was no pain during motion.  There was no effusion, tenderness, patellar tenderness, or patellar grind of either knee present.  Left knee ROM was flexion of 85 degrees (normal 140) and extension of 0 degrees (normal 0).  Right knee ROM was 80 degrees flexion and 0 degrees extension.  Lower extremity strength, sensation, and reflexes were normal.  Bilateral knee X-rays were normal 

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral knee condition 10%, coded analogously to 5003 (degenerative arthritis).  The VA rated each knee condition 10% coded 5003-5260 (degenerative arthritis-limitation of leg flexion), based on the VA C&P examination 1 month after separation, citing consideration of functional loss.  The PEB also adjudicated bilateral CMP as a Category III not unfitting condition.  However, the bilateral PFS and bilateral CMP conditions both refer to the same disability and are not separately unfitting conditions for which a rating may be assigned IAW VARSD §4.14 (Avoidance of pyramiding).  

The Board first considered if both knee conditions remained separately unfitting when decoupled from the PEB’s combined adjudication.  In this case, both knees were imaged and the same pathology was noted and both knees were implicated by the NARSUM.  The Board concluded there was not a preponderance of evidence in the service records which overcame the presumption that the bundled knee condition was reasonably considered separately unfitting.  Board members considered that the objective findings and associated disability for each knee were identical, and therefore the ratings for the knees were considered together.  

A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the NARSUM and VA C&P exams provided satisfactory evidence for limitation of motion of both knees; thus, separate 10% joint ratings are indicated IAW §4.71a.

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) or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  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).  No additional functional limitation was evidenced by the examinations.  There is therefore no VASRD §4.71a route to a rating higher than 10% for each knee under any applicable code, and no grounds for additional rating based on the presence of instability for either knee.  
After due deliberation, considering all of the evidence and mindful of VASRD 4.3 (reasonable doubt), the Board recommends a disability rating as follows: an unfitting right knee and an unfitting left knee, each rated 10%, both coded 5099-5003.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that CMP bilaterally, abdominal muscle weakness, multiple abdominal surgeries including total, hysterectomy, migraine headaches, pulmonary nodule, pulmonary embolism, postpartum, chronic chest pain syndrome, transient alteration of awareness, single, episode conditions were not unfitting.  The PEB also adjudicated obesity as a Category IV condition, a condition that does not constitute a physical disability.  

Abdominal muscle weakness and multiple abdominal surgeries, including total hysterectomy conditions.  The CI had a history of endometriosis controlled by medication and multiple abdominal surgeries including appendectomy, laparoscopy, three cesarean sections (C-sections), and a total abdominal hysterectomy in June 2006.  In May 2005 after the second C-section, the CI reported difficulty doing sit-ups for PRT due to abdominal weakness and numbness around the C-section scar.  She had failed PRT due to the sit-ups three times.  At the time of a third pregnancy in June 2005 the CI was noted to be on profile with PT/PRT limitations.  After the third C-section the CI opted for TAH to definitively treat the endometriosis because pain had returned.  Following the TAH, the CI was on repeat LIMDUs with limitations of no PRT, PT.  There was an emergency room visit for abdominal pain on 27 June 2006.  A CT scan of the abdomen and pelvis noted small bowel adhered to the abdominal wall.  A primary care visit on 7 February 2007 initiated a MEB for abdominal weakness and pain.  The JDETS noted that the CI experienced abdominal pain with sit-ups and crunches and noted the CT findings after the last surgery.  A difficult to read note indicated that the “many” of the CI’s problems were secondary to weight and deconditioning.  The JDETS recommended that the abdominal conditions were Category III (not unfitting).  The MEB NARSUM examination 8 months prior to separation, noted complaint of abdominal muscle weakness.  The CI reported the pain was intermittent and occurs with activity that uses the abdominal muscles, such as sit-ups, crunches, bending, and lifting.  There were no associated gastrointestinal symptoms.  The abdominal examination was normal.  The MEB NARSUM examiner noted the limitations due to the bilateral knee condition and the abdominal condition precluded the CI’s continuation on active duty.  The NMA did not specifically identify any medical conditions, but noted the CI had been unable to pass PRT/PFT.  

The CI was placed on multiple periods of limited duty due to the abdominal conditions.  The abdominal conditions were implicated by the JDETS and the NMA and were judged to fail retention standards.  The Board concluded that the functional implications of the abdominal weakness and pain conditions supported they were unfitting for continued military service at the time of separation and therefore additional disability rating is recommended.  

The VA C&P General Examination 5 November 2008, 1 month after separation, noted complaints of abdominal muscle weakness and generalized pain disorder.  The abdominal examination was normal.  A C&P JOINTS examination dated 9 September 2008, 12 months after separation, noted additional diagnosis listed by the CI’s physical therapist were submitted for additional compensation and included “fibromatosis of muscle ligament and fascia.”  The VA examiner indicated the CI had no information as to what this diagnosis might signify or what symptoms if any could be attributed to this diagnosis and concluded that no such diagnosis was identified.  Under a separate C&P Muscles examination heading, the VA examiner re-iterated the same lack of any history, symptoms, or findings to associate with a muscle diagnosis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the abdominal condition as not unfitting.  The VA rated the abdominal muscle weakness 0%, coded 5319 (muscle group XIX injury - support and compression of the abdominal wall and lower thorax) based on the VA C&P General Medical examination, 1 month after separation and there was no change or additional rating of the abdominal condition after the additional C&P examinations 12 months after separation, citing “no objective evidence of significant abdominal weakness.”  The VA also rated complete hysterectomy 50%, coded 7617 (uterus, both ovaries, removal of).

The CI’s residual disability due to the abdominal condition was due to abdominal pain and weakness and recurrent abdominal adhesions were noted on CT after the hysterectomy.  The Board therefore considered possible coding and rating IAW VASRD §4.73 (muscle injuries) or §4.114 (digestive system) for post-operative adhesions.  The CI underwent TAH for definitive treatment of endometriosis, therefore, rating IAW §4.116 (gynecologic conditions) was not applicable at the time of separation.  The Board first considered coding as 5319 and reviewed the rating criteria, which are subjective, with a 0% rating for `slight’, 10% rating for `moderate’, and 30% for `moderately severe” muscle injury.  The Board considered that when coding the disability analogously as 5319, the discrimination between the `slight’ and `moderate’ characterizations depends on the presence of at least one `cardinal sign or symptom’ of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” for `moderate’, as opposed to none for `slight’.  There had been multiple surgical “injuries” to the abdominal wall that were “deep” and “penetrating” and the CI reported activity limiting abdominal pain and weakness on repetitive use of the muscles in activities such as sit-ups, lifting, or bending.  Therefore, the Board concluded that based on the presence of the cardinal symptoms of loss of power, weakness, lowered threshold of fatigue, and fatigue-pain the disability was best described as `moderate’ and not `slight’ and met the 10% rating, but judged it could not be characterized as `moderately severe’, which by analogy Members judged would require a history of more severe mechanism of injury-more severe or more frequent symptoms and greater objective evidence of muscle abnormalities.  The Board next considered if rating abdominal pain (still present after the last surgery and for which the CI went to the emergency room (ER) for treatment) as secondary to post-operative adhesions (as noted on the CT scan performed at the ER visit) provided higher rating.  The rating criteria of 7301 (adhesions of the peritoneum) provide 10% rating for “moderate; pulling pain on attempting work or aggravated by movements of the body” and there was no evidence of associated partial bowel obstruction for the next higher rating.  There was therefore no higher rating than 10% available with any applicable VASRD code.  Muscle coding was most consistent with the unfitting diagnosis of muscle weakness and the Board chose to code and rate the abdominal condition as 5319.  The Board noted that two abdominal conditions were adjudicated by the PEB.  In this case the abdominal muscle weakness was a consequence of the multiple abdominal surgeries and the two conditions reflect the same disability.  As noted above, IAW §4.14, only one rating may be provided and the total disability due to the conditions is subsumed in the Board’s rating recommendation IAW §4.73.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the abdominal muscle weakness condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5319 and meets the VASRD §4.73 criteria for a 10% rating.  

The migraine headaches, pulmonary nodule, pulmonary embolism, postpartum, chronic chest pain syndrome, transient alteration of awareness, single, episode conditions were not profiled, implicated in the NMA or judged to fail retention standards.  There was no performance-based evidence from the record that any of these condition(s) significantly interfered with satisfactory duty performance at separation.  Additionally, obesity is a condition that does not constitute a physical disability IAW DoDI 1332.38, enclosure 5 and is not eligible for rating.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended migraine headaches, pulmonary nodule, pulmonary embolism, postpartum, chronic chest pain syndrome, transient alteration of awareness, single, episode conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral patella femoral syndrome condition, the Board unanimously recommends a disability rating as follows:  an unfitting right and an unfitting left patella femoral syndrome, each rated 10%, both coded 5099-5003 IAW VASRD §4.71a.  
In the matter of the contended not unfitting “abdominal muscle weakness” and “multiple abdominal surgeries, including total hysterectomy” conditions, the Board unanimously agrees they constituted a single unfitting abdominal condition and unanimously recommends a disability rating of 10%, coded 5319 IAW VASRD §4.73.  

In the matter of the contended CMP bilaterally, abdominal muscle weakness, multiple abdominal surgeries including total, hysterectomy, migraine headaches, pulmonary nodule, pulmonary embolism, postpartum, chronic chest pain syndrome, and transient alteration of awareness, single, episode, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the obesity condition, the Board agrees that it cannot recommend it for additional disability rating.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Patella Femoral Syndrome	5099-5003	10%	
Left Patella Femoral Syndrome	5099-5003	10%	
Abdominal Muscle Weakness	5319	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150320, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 25 Nov 16 ICO XXXXXXXXXXXXXXXXXX    
	(c) PDBR ltr dtd 19 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 19 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 17 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 25 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 19 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 19 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 17 Nov 16 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:
     
     a. XXXXXXXXXXXXXXXXXX, former USN: Effective date of discharge, retroactive placement on the Temporary Disability Retired List with a 50 percent disability rating for six months, followed by a final disability rating of 10 percent. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 60 percent disability rating (increased from 10 percent) effective date of discharge.  

     d. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.  

     e. XXXXXXXXXXXXXXXXXX, former USN: Effective date of discharge, entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent).   

     f. XXXXXXXXXXXXXXXXXX, former USN: Effective date of discharge, entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent).  

     g. XXXXXXXXXXXXXXXXXX, former USN: Effective date of discharge, entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent).

     h. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.     

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)