RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01398
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20041105

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

CI CONTENTION:  The CI made no specific contention.  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 it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040910	VARD - 20050927	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Retropatellar Pain Syndrome	5003-5099	10%	Retropatellar Pain Syndrome, Left Knee	5299-5260	10%	20050901	
			Retropatellar Pain Syndrome, Right Knee	5299-5260	10%	20050901	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:   

Bilateral Retropatellar Pain Syndrome.  The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10%.  This 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 noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and 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 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.  

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in 2000 without specific injury.  Radiographic studies of both knees were normal, but MRI showed a small radial tear of the lateral meniscus of the left knee.  A subsequent MRI in 2004 showed progression of the small radial tear of the lateral meniscus, with no clinical meniscal-specific symptoms.  

At the 11 August 2004 MEB examination, 3 months prior to separation, the CI reported retropatellar pain that was increased by running, prolonged standing, squatting, kneeling and climbing stairs.  Physical examination showed there no tenderness, edema or effusion, and tests for ligamentous laxity and meniscal signs were negative.  Examination of the left knee noted identical findings as the right, including significant patellar grind.  Bilateral knee range of motion (ROM) was 130 degrees flexion (normal 140) and 0 degrees of extension (normal). 

At a 1 September 2005 VA Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported weakness with fatigue, and he avoided activities that aggravated his knee pain, including running, jogging, and prolonged walking.  On examination of both knees, his gait was normal, there was no crepitus and tests for ligamentous laxity were negative.  Bilateral knee ROM was 140 degrees of flexion and 0 degrees of extension.  Bilateral knee ROM after repetition was mildly painful with mild popping.
 
The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 10% as noted above.  The VA rated each knee at 10%, coded analogously to 5260 (leg, limitation of flexion of), citing chronic history of extensive pain, locking and loss of ROM.  The commander’s statement and other STR entries did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Multiple physical therapy evaluations documented painful motion of the knees.  Since undue speculation would be required to conclude the impairment from either knee would not have unacceptably interfered with duty performance, members agreed each knee was reasonably justified as separately unfitting.  Panel members considered the objective findings and associated disability for each knee were identical and agreed the respective ratings should therefore be the same.  

The panel concluded there was sufficient evidence of painful motion and functional loss to support a 10% rating for each knee IAW §4.59 and §4.40.  In considering routes to a higher rating however, there was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (5261).  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 rating higher than 10% for each knee, under any applicable code, and no grounds for additional rating based on the presence of instability.  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee pain condition, each coded 5299-5260.  

BOARD FINDINGS:  In the matter of the right and left knee conditions, the panel unanimously recommends each joint be separately adjudicated as follows:  an unfitting right knee condition coded 5299-5260 and rated 10%, and an unfitting left knee condition coded 5299-5260 and rated 10%, both IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Retropatellar Pain Syndrome, Left Knee	5299-5260	10%	
Retropatellar Pain Syndrome, Right Knee	5299-5260	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161003, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01398.

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,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR