RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02488
BRANCH OF SERVICE:  Marine Corps	SEPARATION DATE:  20070531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Rifleman, medically separated for “patellofemoral pain syndrome, bilateral knees” with a disability rating of 10%.

CI CONTENTION:  Additional unfitting conditions were not considered.  The 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 review of disability ratings assigned 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 or non-compensable.  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 determination 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(s) at the time of separation.  The panel 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 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 - 20070329	VARD - 20090206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Pain Syndrome, Bilateral Knees	5099-5003	10%	Postoperative Meniscectomy, Left Knee With Patellofemoral Syndrome	5259	10%	20090122	
			Postoperative Meniscectomy, Right Knee With Patellofemoral Syndrome	5259	10%	20090122	
Grade II Chondromalacia Patella, Bilateral Knees	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Patellofemoral Pain Syndrome, Bilateral Knees.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left and right knee meniscal damage surgery while deployed to Kuwait in May and June 2005, respectively.

During the 18 December 2005 Reservist Separation Physical Examination the CI marked ‘no’ indicating the member was not physically qualified for separation IAW Naval Regulations.  The planned course of action was:  Temporary Not Physically Qualified, continue physical therapy, and follow up with orthopedics.  On 3 January 2006, the CI was demobilized and placed in a drill status.

From 6 January through 20 Sep 2006 the CI was approved for Marine Corps Medical Entitlements for his bilateral knees, allowing him to receive medical care although not on active duty.  The CI became eligible for both incapacitation pay and medical benefits beginning 21 September 2006.  On 25 September his unit was notified to begin “immediate” medical board proceedings.  The MEB forwarded “chondromalacia of patella” for PEB adjudication.

According to the 17 November 2006 non-medical assessment (commander’s statement), the CI’s injuries hindered him from performing his duties.  There was no limited duty (LIMDU) in STR evidence but the MEB documented the CI was placed on LIMDU which expired 31 January 2007.

At the 31 January 2007 MEB NARSUM, 4 months prior to separation, noted the CI was unable to run a significant amount of mileage with 60 or greater pounds in his pack.  Physical examination noted well healed surgical scars without knee effusion.  Bilateral knee tenderness and step up test with patella crepitation were present.  There was no patellar or knee ligament instability.  Muscle strength was 5/5.  Range of motion was full (measurements not cited); painful motion was not addressed.

There was no VA examination proximate to separation for the panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the patellofemoral pain syndrome, bilateral knees condition 10%, analogously coded 5099-5003 (degenerative arthritis).  The PEB also listed grade II chondromalacia patella, bilateral knees as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The Category II condition was properly subsumed under the overall rating for the patellofemoral pain syndrome, bilateral knees IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated each knee condition 10%, coded 5259 (cartilage, semilunar, removal of symptomatic), based on the C&P examination over 2 year after separation.

The PEB combined the right and left knee conditions under a single service disability rating, 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 panel 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 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 the condition would not cause 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 panel first considered if each knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were profiled (the CI was placed into limited duty), considered to fail retention standards, and implicated by the MEB NARSUM and alluded to as “injuries” in the non-medical assessment.  Members agreed that each knee is reasonably justified as separately unfitting and separate ratings will be recommended.

The panel agreed there was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) 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).  A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the MEB NARSUM and C&P examinations provided satisfactory evidence for the persistence of chronic bilateral knee pain after meniscal surgery (5259); thus, separate joint ratings are supported IAW §4.71a.  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 right knee condition, and 10% for the left knee pain condition, coded 5259.

PANEL FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5259 and rated 10%, and an unfitting left knee condition coded 5259 and rated 10%, both IAW VASRD §4.71a.  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	
Patellofemoral Pain Syndrome, Right Knee	5259	10%	
Patellofemoral Pain Syndrome, Left Knee	5259	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150709, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 22 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(m) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(n) PDBR ltr dtd 21 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(o) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (o) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     h. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     i. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     j. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     k. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     l. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     m. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     n. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXXX
	Acting