RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00439
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060213

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

CI CONTENTION:  The CI contends for his unfitting bilateral knee condition. 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 - 20051227	VARD - 20060801	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Bilateral Patellofemoral Pain Syndrome, Chondromalacia
	5099-5003	10%	Residuals, Right Knee Surgery for Patellofemoral Chondromalacia and Synovitis	5014-5020	10%	20060509	
			Residuals, Left Knee Surgery for Lateral Meniscus Tear	5299-5260	10%	20060509	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY: 

Bilateral Patellofemoral Pain Syndrome, Chondromalacia. The PEB combined the right and left knee conditions under a single 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.  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 the right and left knee 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 CI underwent left knee surgery in January 2005 for a torn lateral meniscus.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral patellofemoral pain” for PEB adjudication.  The permanent profile listed limitations of no running, excessive squatting or climbing and recommended an alternate form of aerobic exercise than the 1.5 mile run.  The commander’s statement implicated both knees as impairing the CI’s duty performance.  An undated MEB NARSUM examination noted complaints of left knee pain indicating the pain was exacerbated with running, cycling, and the frequent squatting required to perform his Air Force duties.  Physical examination showed a normal gait with full range of motion, and no joint line tenderness.  Lower extremity strength was 5/5.

At the VA Compensation and Pension (C&P) examination in May 2006, performed 3 months after separation, the CI reported constant knee pain, aggravated by weight bearing activities, with weakness and fatigue, occasional popping and locking.  The CI was not using any assistive devices.  Physical examination showed normal posture and gait.  There was bilateral crepitus and tenderness, without effusion.  Bilateral knee ROM was reported as flexion to 130 degrees (normal 140), and extension to 0 degrees (normal 0), with painful motion noted.  There was no additional loss of ROM with repetition.  Stability tests were normal.

The Board first considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The CI underwent surgery of both knees during active duty with residual pain and functional limitations reported equally after surgery for both knees.  The permanent profile listed physical limitations that would apply to both knee conditions equally and the commander’s statement implicated both knee conditions.  The Board concluded there was not a preponderance of evidence in the STR which overcame the presumption that the bundled knee condition was reasonably considered separately unfitting.  The Board then considered its rating recommendation for the unfitting left knee condition at the time of separation.

The PEB assigned a 10% rating under an analogous 5099-5003 code (arthritis, degenerative) for the bilateral knee condition.  The VA assigned a 10% rating for the left knee using an analogous 5299-5260 code (leg, limitation of flexion of) based on the VA C&P examination 3 months after separation, citing imitation of leg flexion.  

A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the MEB NARSUM and VA exams provided satisfactory evidence for painful motion or pain with use of both knees; thus, separate joint ratings are indicated IAW §4.71a.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) coded analogous to 5003 for patellofemoral pain.  The persistence of pain after meniscal surgery could also support a 10% rating under the 5259 code (cartilage, semilunar, removal of symptomatic).  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).  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 therefore no VASRD §4.71a route to a rating higher than the 10% under any applicable code, and no grounds for additional rating based on the presence of instability.  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, coded 5099-5003.

Right Knee.  According to STR and the MEB NARSUM, the CI underwent right knee surgery in August 2005 for inflammatory synovitis and chondromalacia of the patellofemoral joint.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral patellofemoral pain” for PEB adjudication.  A computer generated undated MEB NARSUM examination noted complaints of right knee pain indicating the pain was exacerbated with running, cycling, and the frequent squatting required to perform his Air Force duties.  Physical examination showed a normal gait with full range of motion, and positive medial joint line tenderness.  

At the VA Compensation and Pension (C&P) examination in May 2006, performed 3 months after separation, the CI reported constant knee pain, aggravated by weight bearing activities, with weakness and fatigue, occasional popping and locking.  The CI was not using any assistive devices.  Physical examination showed normal posture and gait.  There was crepitus and tenderness, but no effusion.  Bilateral knee ROM was reported as flexion to 130 degrees (normal 140), and extension to 0 degrees (normal 0), with painful motion noted.  There was no additional loss of ROM with repetition.  Stability tests were normal.

The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. By the same reasoning as elaborated under the left knee discussion 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.  The Board then considered its rating recommendation for the unfitting right knee condition at the time of separation.  The PEB assigned a 10% rating under an analogous 5099-5003 code (arthritis, degenerative) for the bilateral knee condition.  The VA assigned a 10% rating for the right knee using an analogous 5014-5020 code (osteomalacia and synovitis) based on the VA C&P examination 3 months after separation, citing painful or limited motion of a major joint.  As noted under the left knee rating discussion a bilateral 10% rating under the provisions of 5003 was considered, but the Board concluded that the MEB NARSUM and VA exams provided satisfactory evidence for painful motion or pain with use of both knees for separate joint ratings.  By the same rationale as elaborated under the left knee rating discussion a 10% rating for the right knee was supported based upon painful motion with functional loss coded as 5099-5003 for patellofemoral pain.  There was no higher rating available under any applicable code for the right knee and no grounds for additional rating based on the presence of instability.  

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.

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting left knee condition and an unfitting right knee condition, each rated 10%, both coded 5099-5003 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	
Left Knee Pain	5099-5003	10%	
Right Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, 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-2015-00439.

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,

Attachments:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR