RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01455
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20041112

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

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 - 20040618	VARD - 20050330	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome	5099-5003	10%	Left Knee Status Post Arthroscopy for Patellofemoral Syndrome…	5010-5259	10%	20041215	
			Right Knee Patellofemoral Syndrome	5299-5260	0%	20041215	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed bilateral knee pain in March 1999 without specific injury.  X-rays and MRI of the left knee were normal.  A CT scan of the left knee showed malalignment of the tibial tubercle and trochlear groove which exceeded published standards.  The CI underwent left knee diagnostic arthroscopy in July 2003 and left knee patellar lateral release in December 2003.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded bilateral knee pain for PEB adjudication.

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

Knee ROM
(Degrees)	MEB ~8 Mos. Pre-Sep	Ortho ~6 Mos. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
	Left	Right	Left	Left	Right	
Flexion (140 Normal)	135	135	“full”	140	140	
Extension (0 Normal)	0	0		0	0	
Comment	Patellar grind; Lachman’s 1+ w/ firm endpoint	-	Painful motion; tender knee and at joint line	Tenderness; history of meniscal surgery	Tenderness	
§4.71a Rating	0%-10%	0%	10%	10%	0%	

According to the commander’s statement dated 10 March 2004, the CI’s “knee problems have resulted in 7 duty profiles that have kept him from performing his duties.”  “His knees appear to be getting worse, not better, even after surgeries and therapy.”

The MEB NARSUM dated 26 March 2004, 8 months prior to separation, noted complaints of bilateral knee grinding and locking along with daily 3 of 10 pain.  The MEB physical examination noted slightly decreased ROM as indicated in the chart above without mention of pain on motion.  On the left knee, the CI had sensitivity laterally; a positive patellar grind test; and slight patellar maltracking.  The left knee was stable and there was no effusion or joint line tenderness.  The diagnoses were bilateral patellofemoral syndrome with arthroscopically confirmed osteoarthritis of the left patella (status post lateral release), and left iliotibial band syndrome.

At the time of the orthopedic clinic appointment on 12 May 2004, 6 months prior to separation, the CI reported sharp pain on the outside of his left knee and a “mild degree of swelling.”  On examination the CI had a moderate degree of tenderness on the outside of his left knee and along the medial and lateral joint line.  The CI had full left knee ROM as indicated in the chart above with pain on flexion and extension.  There was no sign of effusion and no examination of the right knee.  Duty limitations were recommended by profile dated 10 August 2004, including “no military formations, sports, running, prolonged walking, or standing.”

At the 15 December 2004 VA Compensation and Pension (C&P) evaluation, performed 1 month after separation, the CI reported “loss of motion in left knee with pain being the limiting factor” and constant bilateral knee pain aggravated by squatting, kneeling and stair climbing.  The CI denied weakness, fatigue, or lack of endurance following repetitive use for either knee.  X-rays of both knees were interpreted as normal.  Physical examination showed tenderness to the outside of the knee and to the patella of both knees.  The CI had a normal gait as well as normal ROM as indicated in the chart above, without mention of painful motion.  Repetitive motion produced no limitations.  There was no ligamentous instability or quadriceps muscle atrophy noted.

The PEB combined the left and right knee 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 Board first considered if the left knee condition and the right knee condition, having been de-coupled from the combined PEB adjudication, each remained separately unfitting as established above.  Board members agreed that the evidence reasonably justified that the functional limitations of the left knee condition and of the right knee condition contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating for each knee could be recommended.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee conditions together at 10%, analogously coded 5099-5003 (analogous to degenerative arthritis).  The VA rated the left knee condition 10%, analogously coded 5010-5259 (traumatic arthritis - removal of semi-lunar cartilage, symptomatic) based on the VA C&P examination 1 month after separation, citing symptomatic removal of the semilunar cartilage.  The VA rated the right knee condition 0%, analogously coded 5299-5260 (leg, limitation of flexion), citing normal ROM and no evidence of functional loss.

The Board agreed there was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) in either knee.  However, there was evidence of painful motion with functional loss (based on §4.59, §4.40 and §4.45) in the left knee by the orthopedic examination to support a 10% rating for that knee, but there was no evidence of painful motion in the right knee for a 0% rating.  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 for either knee (despite VA coding, operative reports did not indicate any meniscal pathology of the left knee).  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) for either leg.  No additional functional limitation was evidenced by the examinations for either knee.

Separate knee unfit determinations and individual ratings of the left knee at 10% and the right knee at 0% for a combined 10% rating, would offer no benefit to the CI.  Therefore the Board concluded there was not sufficient evidence to support a rating higher than the combined 10% 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 bilateral knee 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 20150615, 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-2015-01455.

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
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings