RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01248
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060508

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Tactical Aircraft Maintenance Journeyman, medically separated for “bilateral knee pain associated with patellofemoral syndrome,” with a disability rating of 10%.

CI CONTENTION:  The CI contended for his knees and asked the Board to “review all conditions”.   The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20060310	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain Associated with Patellofemoral Syndrome	5099-5003	10%	No VA Examination in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Knee Pain Associated with Patellofemoral Syndrome (PFS).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain, which was diagnosed as PFS began in 2003, although he reported an injury in basic training to the right knee, which healed without sequelae.  In November 2003 examination revealed a 5 degree lateral patellar tilt but no patellar instability.  X-rays of the knees revealed lateral tilt and subluxation of the patellae.  Because of persistence of pain and no relief with anti-inflammatory medication, physical therapy, and steroid injections, the CI underwent left knee surgery on 6 January 2005 for a lateral retinaculum release (tissue on the outside of the patella) and plica (an extension of the protective synovial capsule of the knee) excision, which was followed by physical therapy.  The CI then underwent right knee surgery on 31 March 2005 for lateral retinaculum release and was again followed by physical therapy.  At a physical therapy (PT) clinic examination on 5 May 2005, 1 month post-surgery on the CI’s right knee, 4 months post-surgery on the CI’s left knee and 12 months prior to separation, the CI reported no pain. Physical examination documented the CI’s gait was within normal limits and the range of motion (ROM) was 125 degrees.  By July 2005 the knee was “completely healed.”  In September 2005 the CI reported he fell on his knee 6 weeks earlier and had pain since that time.    

The 12 September 2005 MEB NARSUM examination, 8 months post left knee surgery and 1 month prior to right knee surgery and 8 months prior to separation, the examiner noted the CI had been dealing with chronic pain that had not improved with surgical procedures and physical therapy.  The CI’s profile permanently prevented him from kneeling, squatting, running and lifting.  Physical examination showed right knee tenderness at the anterior lateral portion of the patella, with negative testing for instability.   The left knee was not examined.  

Having reached a plateau in his rehabilitation due to scarring, which caused stiffness in the knee, the CI underwent right knee arthroscopic lysis of adhesions, manipulation under anesthesia, and an arthroscopic lateral release on 13 October 2005.  An orthopedic surgeon recommended the CI be permanently restricted to sedentary work, while an orthopedic note dated 16 November 2005 indicated the CI had chronic subluxating patellae (kneecaps) and underwent three surgeries on the right knee and one surgery on the left knee from which he was unable to perform his duties.    At a physical therapy examination on 25 October 2005, the CI experienced pain at 5/10.  Pain was improved with sitting and lying down, while standing and walking made the pain worse.  Physical examination revealed the CI ambulated with crutches and there was tense edema of the right lateral leg and knee.   Stability testing of the left knee was reported as normal although the diagnosis was s/p right lateral release and debridement, while girth measurements of the left lower extremity were documented to be less than the right. 

The ROM evaluations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. 

Knee ROM
(Degrees)	PT ~12 mos. Pre-Sep
	MEB ~8 Mos. Pre-Sep
	PT ~7 Mos. Pre-Sep
	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)		125	Not examined	Full ROM	148 	90**	
Extension (0 Normal)				Full ROM	2	3	
Comment	Gait normal; no pain		TTP; no effusion; no instability	Using crutches; edema; no instability on left; quadriceps atrophy on left	
§4.71a Rating		0%*		0%	0%	0%	
   *Assumes extension nearly normal and in line with proximate exams to this date
** ROM measurement taken 10 days post right knee arthroscopic procedure

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 (arthritis, degenerative) 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 panel 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 panel’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 panel 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 panel 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 is presented together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.  With respect to each knee, there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not indicate the presence of ligamentous instability or laxity (5257); however, an orthopedic examiner indicated the CI had chronic subluxating patellae and the MEB referral to the PEB included bilateral unstable patellae.  Furthermore, 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).  As noted above, there was no distinction with regard to clinical features or fitness considerations between the right and left knee.   The bilateral diagnosis supported a single 5003-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. Members agreed, therefore, that the evidence did not support recommending separate right and left knee disability ratings.  Alternatively, since an orthopedic examiner noted chronic subluxating patellae, panel members considered whether a separate rating for each knee was reasonable.  While it is not inappropriate to recommend a rating for each knee since patellar subluxation falls under the 5257 code (knee, other impairment of), the patellar subluxation was noted prior to the knee surgeries.  Therefore, it would be speculative to provide a rating for each knee in the absence of more qualitative or quantitative evidence proximate to separation, which could support a rating that could differentiate slight, moderate, or severe.  After due deliberation, and considering all of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled knee conditions.

BOARD FINDINGS:  In the matter of the bilateral knee pain with associated patellofemoral syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.   There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150609, w/atchs
Exhibit B.  Service Treatment Record

SAF/MRB
XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01248.

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,

Attachment:
Record of Proceedings