RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01896
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070810

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Ground Radio Maintainer, medically separated for “bilateral knee pain,” with a disability rating of 10%.

CI CONTENTION:  The CI contends for a higher rating.  The 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 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 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 - 20070621	VARD - 20071019	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	10%	Left Knee Post-Surgical Residuals	5260	0%	20070612
	
			Right Knee Post-Surgical Residuals	5260	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:    

Chronic Bilateral Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a several year history of chronic bilateral knee pain.  He underwent multiple right knee surgeries for plica removal and lateral patellar release and a left knee arthroscopy in 2000 with plica removal.  Magnetic resonance imaging of both knees 24 October 2006 was normal and an orthopedic specialist indicated “there is little pathology present” and recommended no further treatment.  A primary care visit dated 14 November 2006 noted the CI was able to deploy and perform his job with profile restrictions of no running and biking.  The CI disagreed and requested a second orthopedic opinion.  Bilateral knee X-rays on 15 February 2007 showed marked lateral patellar displacement, right greater than left and lateral patellar tilt on the right.  At the second opinion evaluation on 1 March 2007, 5 months before separation, the CI reported bilateral knee pain and swelling with buckling of both knees, but no locking.  The CI did not report any instability of the right knee.  The physical examination of the bilateral knees showed a positive patellar grind test.  There was bilateral patellar laxity and palpation of the patella reproduced most of the CI’s pain bilaterally.  There was no joint line tenderness, effusion, or patellar crepitus.  Bilateral knee ROM was extension 0 degrees (normal 0) and flexion 140 degrees (normal 140).  There was no evidence of functionally significant instability (some anterolateral rotary instability noted but multiple other tests for instability were negative - negative drawers, Lachman’s, and pivot shift).  The diagnosis was bilateral patellofemoral syndrome and a MEB was recommended because the only further treatment recommended was activity and environmental modifications.  The MEB forwarded “bilateral knee pain,” for PEB adjudication.  The CI’s profile limitations included no running or bicycling, no lifting more than 25 pounds, no climbing or working at heights.  The commander’s statement did not specifically mention right, left, or bilateral knees.  The commander noted that the CI was not worldwide deployable, but was able to perform all in-garrison duties with his current limitations and work arounds.  However, activities such as running, squatting, stooping or kneeling could prevent him from performing his duties in the future and restrict his deployability depending on deployment location and environment.  

The MEB NARSUM examination on 22 March 2007, 5 months prior to separation, noted complaints of continued bilateral knee pain.  Physical examination cited the second opinion orthopedic evaluation in March 2007 summarized above.  The MEB NARSUM examiner indicated that he concurred with the CI that he was unable to fulfill the athletic requirements of active service duty and specifically listed difficulty with running and lifting.  NARSUM updates 10 April and 4 May 2007 indicated there had been no change in CI’s reported knee symptoms.  At a primary care evaluation on 8 May 2007, 3 months before separation, the CI reported right knee pain with cracking of the right knee when he tried to straighten it the night before with pain and swelling.  The physical examination noted a limp.  There was “tenderness observed on ambulation of the knees.”  There was tenderness to palpation of the back of the right knee with pain with extension.  Right knee X-rays showed a possible loose body within the joint that had not been seen on previous films.  The CI was given crutches for a few days.  

At the 12 June 2007, VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported a long history of bilateral knee pain aggravated by activity.  He stated his symptoms included weakness when climbing stairs, swelling, giving way, and lack of endurance when performing physical activity.  The pain was constant and graded 7/10.  He reported he could function with the pain with medication.  He endorsed incapacitating episodes as often as one time per year.  The VA examiner indicated the functional impairment was no running, difficulty with stairs and lifting.  Physical examination showed a normal gait.  The CI was not using any assistive devices for ambulation.  There was tenderness bilaterally.  There was no recurrent subluxation, effusion, or crepitus noted.  There was no instability or lateral laxity noted and tests for meniscal pathology were negative.  Bilateral knee exam showed normal flexion of 140 degrees and extension of 0 degrees.  There was no additional loss of ROM with repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions as a single unfitting condition coded 5099-5003 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 PEB rated the bilateral knee condition 10%, coded analogously to 5099-5003 (arthritis, degenerative), citing DoDI and VASRD guidelines.  The VA rated the left and right knee condition 0% each coded 5260 (leg, limitation of flexion), based on the VA C&P examination 2 months before separation, citing non-compensable ROM and lack of residual functional impairment.  

The Board first considered if both the right and left chronic knee pain conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile and commander’s statement both referenced limitations equally applicable to both knees.  The MEB NARSUM addressed both knees and the findings and diagnoses of both knees were the same.  The orthopedic second opinion noted that the patellofemoral syndrome of each knee could only be managed by activity and environmental modifications that precluded continued active duty.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the each knee condition was reasonably considered separately unfitting.  Since the diagnosis and clinical findings for the knees were the same the Board then considered its rating recommendations for the unfitting right and left knee pain conditions together at the time of separation.  

As noted above, there are no distinctions with regards to clinical features or disability considerations at the time of separation between the right and left knees.  The bilateral patellofemoral diagnosis supported a single rating for “2 or more major joints” without compensable limitations or painful motion coded as 5099-5003, an analogous code for PFS; thus there is VASRD §4.71a latitude for a bilateral rating.  The Board reviewed to see if either or both knees met criteria for higher rating under 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).  Following his knee surgeries there was laxity of the patella noted proximate to separation but there was no evidence of recurrent patellar subluxations or dislocations (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 insufficient evidence at the MEB NARSUM and VA examinations of painful motion of either knee to support a 10% rating for each knee (based on §4.59, §4.40 and §4.45).  Members agreed, therefore, that the evidence did not support recommending separate right and left knee disability ratings.  Therefore, after having unbundled the knees and recommended each knee as unfitting, the Board found there was no VASRD §4.71a route to a rating higher than the combined 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability and no change to the PEB adjudication is recommended.  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 chronic bilateral knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain 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 20150618, 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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01896.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings