RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01275
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20051220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Contracting Journeyman, medically separated for “patellofemoral chondromalacia, bilateral,” with a disability rating of 20%.

CI CONTENTION:  “Review all 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 - 20051107	VARD - 20111104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patellofemoral, Bilateral	5099-5003	10%	Left Knee Condition	5260	NSC	STR	
			Right Knee Condition	5260	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Patellofemoral Chondromalacia, Bilateral.  A The PEB combined the right and left patellofemoral chondromalacia conditions as a single unfitting condition 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 below, 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 pain condition began in 2002 in Basic Training.  Initial orthopedic evaluation in January 2005 noted retropatellar tenderness without evidence of instability or meniscal damage and bilateral radiographic (X-rays) studies were normal.  Magnetic resonance imaging scans of the right and left knees in March 2005 were also normal.  The right knee pain was worse than the left and the CI underwent right knee arthroscopy in June 2005 for with debridement of some patellofemoral arthritis (grade 1-2/4) and synovitis.  The post-operative diagnoses were chondromalacia patella and synovitis.  At a follow-up visit on 9 June 2005, the orthopedic surgeon noted the CI’s problem was likely due to abnormal patellar tracking causing arthritis which began with the demands on the knees in Basic Training.  Orthopedic follow-up in August 2005 noted the right knee was “doing quite well” with mild aching reported since the CI had stopped taking anti-inflammatory medication.  Left knee arthroscopy was discussed but the CI was not sure she wanted to proceed with that at the time.  Despite treatment, the bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral knee pain” for PEB adjudication.  

The CI was given an L4 profile with physical limitations including no running, no prolonged walking or standing, no stairs or climbing, no lifting greater than 10 pounds and no physical fitness testing except waist circumference.  The commander’s statement implicated the bilateral knee injuries as impairing the CI’s ability to participate in exercise or be world wide deployed.  The MEB NARSUM examination in October 2005, 2 months prior to separation, noted complaints of “bilateral knee pain and no neurological complaints.”  As a result, the CI was unable to take or pass the physical fitness test.  Physical examination showed bilateral retropatellar tenderness, lateral patellar tracking, and “full range of motion.”  The MEB NARSUM examiner indicated that “persistent bilateral knee pain” impaired the CI’s performance of physical fitness activities or prolonged walking or standing.  The MEB examination (recorded on DD Form 2697) dated 16 November 2005, 1 month prior to separation noted bilateral knee pain.  The physical examination noted normal gait, strength, and neurological examination with a difficult to read handwritten notation which appeared to indicate decreased lower extremity range of motion due to pain.  There was no VA Compensation and Pension examination in evidence, the CI failed to report to a scheduled appointment on 28 September 2011.

The Board first considered if both knee conditions remained separately unfit when separated from the PEB’s combined adjudication as elaborated above.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  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.  There were no clinical distinctions between the right and left knees noted at the MEB examinations and therefore the Board directed attention to its rating recommendations for both knee conditions together at the time of separation.

The PEB rated the bilateral knee condition 10%, analogously coded 5003 (arthritis, degenerative).  The VA did not service-connect the bilateral knee condition coded 5260 (leg, limitation of flexion of), based on VA rating decision 6 years after separation, citing the STRs citing “no chronic disease or injury residual shown in service and no disability was found in the current evidence of record.”
As noted above, there are no distinctions with regards to clinical features of the right and left knee joint.  The right knee pain was initially worse than the left, but both knees were treated by physical therapy and both knees were imaged and at the MEB NARSUM examination, after right knee surgery, the examination of both knees was the same.  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.  

The Board consensus was that there was insufficient evidence of painful motion as defined under 5003 for a 10% rating for each knee joint individually.  The Board reviewed to see if a higher rating was available for either or both knees with any applicable code.  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 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).  There was therefore 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.  Therefore, having unbundled the knees the Board recommends a 10% rating for the paired joint conditions as adjudicated by the PEB.  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 knee condition.  

BOARD FINDINGS:  In the matter of the patellofemoral chondromalacia, bilateral 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 20150615, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01275.

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