RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01835
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20060616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Services Journeyman, medically separated for “bilateral anterior knee pain,” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  The CI’s 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 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 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 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 panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 2006426	VARD - 20070727	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Anterior Knee Pain 	5099-5003	0%	Left Knee, DJD	5260-5003	10%	20080715	
			Right Knee - No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Anterior Knee Pain.  The PEB combined the left and right knee pain diagnoses as a single unfitting condition under a single code and rating citing the condition existed prior to service and may have been service aggravated.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under VASRD criteria of 5003, and that this approach does not necessarily 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 that it alone would not have caused 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 bilateral knee pain condition is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in February 2004 when she twisted her left knee while moving water bottles. Left knee magnetic resonance imaging (MRI) revealed subtle medial femoral condylar articular cartilage edema (excess tissue fluid swelling).  There no evidence of surgical procedures on either knee. 

An orthopedic examination on 4 January 2006, 5 months before separation, noted complaints of bilateral knee pain (L>R) with occasional swelling and limping.  The pain was worse when she was on her feet at work for 10 to 13 hours.  She felt her knees may buckle occasionally but did not have an episode of falling.  Physical examination revealed the ability to rise, stand, and ambulate without identifiable limp.  The bilateral knee examination revealed tenderness at the pes bursae (moderate), and joint lines (minimal), with no effusion (fluid collection).  Active range of motion (ROM) was greater than normal (0-140 degrees normal). There was full flexion and 5-6 degrees of hyperextension.  There was no ligamentous instability or meniscus pathology and painful motion not addressed.  

The MEB NARSUM examination on 1 March 2006, 4 months before separation, noted complaints of left knee pain.  The left knee examination revealed tenderness at the inferior patellar tendon with no joint line tenderness, effusion, or deformity.  Active ROM was full (0-140 degrees). There was no ligamentous instability and painful motion not addressed.  The right knee was not examined.  

At the 27 June 2007 VA Compensation and Pension (C&P) evaluation, 13 months after separation, the CI reported left knee pain from arthritis since 2001, which felt tired, stiff, and swelled with prolonged movement or walking, and locked when the knee was numb or tired.  There were no right knee pain complaints.  The left knee examination revealed tenderness “under knee cap and around the knee” and edema.  Left knee active ROM showed a normal flexion of 140 degrees and normal extension of 0 degrees.  Joint function was additionally limited by pain and lack of endurance, but was not additionally limited by fatigue, weakness, or incoordination, after repetitive use.  There was no ligamentous instability or meniscus pathology.  The right knee examination revealed no tenderness, effusion, edema, redness, heat, subluxation, crepitus (grating sensation or sound), abnormal movement, guarding of movement, or weakness.  Right knee active ROM showed a normal flexion of 140 degrees and a normal extension of 0 degrees.  Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  There was no ligamentous instability or meniscus pathology. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing the condition existed prior to service that may have been service aggravated.  The VA rated the left knee condition 10%, coded 5260-5003 (leg, limitation of flexion-degenerative arthritis) based on the C&P examination 13 months after separation, citing painful motion.  The CI did not file a right knee VA disability claim.  

The panel considered if the left or right knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Neither knee was specifically profiled or cited by the commander’s performance statement as a duty limiting condition.  The right knee was only evaluated by orthopedics, 17 and 5 months before separation, with left knee pain complaints greater than the right.  Subsequent knee examinations did not offer a right knee impairment, imaging, treatment, or diagnosis.  The panel majority agreed the left knee’s pathology, chronic clinical acuity, and treatment was more functional impairing than the right knee.  The panel majority determined the STR evidence supports the left knee as reasonably justified as separately unfitting, while the right knee was not separately unfitting.  

Panel members agreed there was no left knee limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was sufficient STR evidence of functional loss to support a 10% rating (based on (§4.40 and §4.45).  There was no evidence of subluxation or lateral instability to support a separate 10% rating under the 5257 code (knee, other impairment).  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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition IAW §4.40 (functional loss) analogously coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral anterior knee pain condition, the panel majority recommends it be adjudicated for two separate conditions.  In the matter of the left knee condition, the panel majority recommends a separately unfit determination with a disability rating of 10%, coded 5099-5003.  In the matter of the right knee condition, the panel majority agrees that it cannot recommend a finding of unfit for additional disability rating.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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 Anterior Knee Pain condition	5009-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150703, w/attachments
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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01835.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR