RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01867
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E3, Signal Support Systems Specialist, medically separated for “bilateral patellar-femoral syndrome,” rated 10% each, with a combined disability rating of 20%.

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 – 20080422	VARD - 20081021	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Patellofemoral Syndrome	5099-5003	10%	Right Retropatellar Pain Syndrome	5299-5260	NSC	20080920	
Left Patellofemoral Syndrome	5099-5003	10%	Left Retropatellar Pain Syndrome	5299-5260	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  The PEB rated the right and left knee separately at 10% each, but combined the conditions under one rating.  According to Service treatment record (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the CI developed bilateral knee pain during her 3rd week of basic training.  An 8 January 2008 right knee magnetic resonance imaging (MRI) study was unremarkable.  The 10 January 2008 right knee radiographic (X-rays) revealed an ossific (bony) density within the patellar tendon consistent with an old injury.  

At the 4 February 2008 orthopedic surgery appointment, the CI complained of bilateral knee pain behind the patellae.  The bilateral knee examination revealed normal appearance and patellofemoral region tenderness.  Pain-free knee range of motion (ROM) was normal.  The patellar grind (assesses abnormal patellar movement and painful crepitation) tests were positive and the anterior/posterior drawer (assesses anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]) and McMurray (assesses menisci) tests were negative.  The examiner recounted the findings of the right knee MRI and X-rays.  The assessment listed patellofemoral syndrome ([PFS] anterior knee pain symptom complex involving patella) and the examiner opined there was no indication for surgery. 

At the 11 February 2008 physical therapy (PT) appointment for MEB ROM measurements, the physical examination documented a mild antalgic (assuming a gait or posture to lessen pain) gait pattern.  The bilateral knee examination revealed no swelling, edema (excess tissue fluid swelling), or mechanical block to ROM.  Pain-limited ROM was flexion of 130 degrees (normal 140) and a normal extension of 0 degrees.  

At the 28 March 2008 MEB NARSUM, 2 months before separation, the CI complained of constant bilateral knee 5/10 pain.  Pain was exacerbated to 10/10 with prolonged sitting, prolonged physical activity, and stairs.  The bilateral knee examination revealed no scars, deformities, or effusion (fluid collection).  There was patellar tendon, patella lateral facet, and patella superior/inferior pole tenderness.  There was no medial/lateral joint line, femoral condyle, or tibial plateau tenderness.  The ROM was flexion of 130 degrees and a normal extension of 0 degrees.  The patellar grind tests were positive and the anterior/posterior drawer, McMurray, and valgus/varus stress (assesses medial collateral ligament [MCL]/lateral collateral ligament [LCL]) tests were negative.  The Lachman (assesses ACL) tests were 1/A (< 5mm translation/firm endpoint).  The examiner recounted the findings of the unremarkable right knee MRI and bilateral knee X-rays.  The diagnosis listed chronic bilateral PFS.  

At the 20 September 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI complained of constant bilateral (R>L) knee 4/10 pain.  She stated “that both knees have a tendency to buckle and lock up.”  Pain was exacerbated with prolonged standing, prolonged walking (> 1 mile), and stairs.  The physical examination documented a normal gait.  The bilateral knee examination revealed a mild genu valgus deformity with no tenderness, effusion, crepitus (grating sensation or sound), or ligamentous instability.  Repetitive ROM was a normal flexion of 140 degrees and a normal extension of 0 degrees.  The McMurray tests were negative.  The examiner recounted the findings of the bilateral knee X-rays.  The impression listed bilateral retropatellar pain syndrome.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee conditions 10% each, coded analogously to 5099-5003 (degenerative arthritis), citing painful motion on each knee.  The VA did not service-connect either knee, coded analogously to 5299-5260 (limitation of leg flexion) citing the conditions existed prior to service and were without permanent service aggravation.  

Panel members considered that the objective findings and associated disability for each knee were similar, and agreed the respective ratings should therefore be the same.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for either knee; however, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right and left knee conditions.  

BOARD FINDINGS:  In the matter of the bilateral 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009225, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       
						      					
Enclosure