RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01072
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Trainee, medically separated for “bilateral patellofemoral syndrome,” with a disability rating of 10%.  

CI CONTENTION The CI made no specific contention.  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 on 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 - 20060601	VARD - 20070130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome	5099-5003	10%	Left Patellofemoral Disorder	5260	0%	20061223	
			Right Patellofemoral Disorder		0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome (PFS).  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously as 5099-5003 (degenerative arthritis) 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 Disability Evaluation System 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 (NARSUM), the CI’s reported to Trainee Health on her second day of Basic Training (BT) with complaints of bilateral knee pain without trauma or injury.  There were no range of motion (ROM) measurements in the record.  Radiographic studies showed normal knees.  In April 2006, she was evaluated by sports medicine and orthopedic specialists and both of whom agreed with the diagnosis of bilateral PFS.  Both agreed that the CI could require up to 6 additional months to fully heal before she could return to BT.  There was no surgical indication.  The MEB forwarded “patellofemoral syndrome, bilateral” for PEB adjudication.  

The MEB NARSUM examination on, 10 May 2006, a month prior to separation, noted the CI reported bilateral knee pain aggravated by activity.  There was tenderness to palpation of the right knee and a positive patellar grind test, with a small effusion.  The left knee was tender to palpation and there was “clicking” with ROM.  There was no evidence of instability or meniscal injury of either knee.  

At the 23 December 2006 VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI presented with no acute distress.  The physical examination showed a non-antalgic gait and forward flexion of both knees to 135 degrees (140 normal).  She had no pain on ROM measurements or pain or additional limitation with repetitive motion.  There was no instability of either knee, no significant medial, lateral joint line tenderness and patellar tracking was normal.  The examiner did note a mild amount of tenderness behind the posterior of the patella.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded analogously as 5099-5003 (degenerative arthritis), citing DoD and VASRD guidelines.  The VA rated the left and right knee conditions separately at 0% each coded 5260 (leg, limitation of flexion), citing no evidence of leg limitation of flexion to 60 degrees.  Directing attention to its recommendations, the Board first considered if both the right and left knee conditions met the Board’s fitness threshold for separate ratings (as elaborated above). There was no permanent profile or commander’s statement in record.  However, the evidence clearly supports the CI was treated for bilateral knee pain and was found to fail retention standards by the MEB NARSUM examiner for bilateral PFS.  The Board therefore 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 and left knee conditions at the time of separation.  

As noted above, there are no distinctions with regards to clinical features fitness considerations between the right and left knee.  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.  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 no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no painful motion of the knees mentioned at the MEB NARSUM exam and the VA C&P exam documented no pain with ROM, even with repetition.  The bilateral diagnosis supported a single 5003-based rating for “2 or more major joints” without compensable limitations or painful motion (as also applied by the VA); thus there is VASRD §4.71a latitude for a bilateral rating.  Members agreed, therefore, that the evidence did not support recommending separate right and left knee disability ratings and concluded that the evidence supported the PEB’s decision to rate both knees together under the 5003 VASRD code.  There was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  After having unbundled the bilateral PFS condition the Board found there was no ratings benefit to the CI and therefore recommends no change to the PEB adjudication.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral PFS condition.  

BOARD FINDINGS:  In the matter of the bilateral patellofemoral syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20150610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01072.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXXXX

Attachment:
Record of Proceedings