RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-01444
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Aircraft Armament Systems Journeyman, medically separated for “patello femoral [sic] syndrome” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  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 - 20050427	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Syndrome	5399-5003	10%	No VA ratings	
Tobacco Habituation	Cat III		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Patellofemoral Syndrome.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 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 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 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 adjudicated by the PEB.  The evidence for the right and left knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Knee.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in December 2002 after walking.  MRI studies showed joint effusion, mild thinning and attenuation of the anterior cruciate ligament (ACL), without evidence of tear, and a possible strain or sprain of the ACL.  There was no surgical indication.  

At the 7 January 2005 orthopedic clinic appointment, 5 months prior to separation, the examiner recorded the CI’s walking distance was markedly limited to one block and she had pain both at rest and with activity.  It hurt to climb stairs and the knee tended to give out on her.  She had a fair degree of popping and it was difficult for her to get up from a low chair.  On examination she walked with a limp, very slowly, and appeared to be in a great deal of discomfort.  The left knee showed a slight degree of effusion without wasting of the quadriceps.  Bilateral knee range of motion (ROM) showed 120 degrees of flexion (normal 140) and 0 degrees of extension (normal) with a slight degree of discomfort on the patellofemoral joint on the left side.  The patella was stable.  There was tenderness predominantly over the medial joint line.  Ligaments were intact and provocative testing showed a stable knee.    

The 17 March 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic daily pain.  It was noted the CI had been given several different nerve blocks in the past and had some relief.  She had a TENS unit which she used at home and it sometimes helped.  Physical examination showed left knee tenderness along the medial joint line and very painful flexion, but ROM measurements were not recorded.  

At the 22 March 2005 Health Sciences Services Clinic appointment, 3 months prior to separation, the examiner recorded the CI was status post left knee neuroma injection.  She continued to have a constant, sharp, shooting pain over her left knee.  On examination, there was normal ROM of the left knee with no pain.  There was significant tenderness “over left knee neuroma over tibia.”  Sensory was grossly intact.  The 12 April 2005 commander’s statement specifically named both knees as being problematic.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the left knee condition met the threshold for separate rating (as elaborated above).  The left knee was profiled, implicated in the commander’s statement and judged to fail retention standards.  There was performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  Therefore, panel members agreed the left knee condition was reasonably justified as separately unfitting.  The PEB rated the bilateral knee condition 10%, coded analogously as 5003 (degenerative arthritis).  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no history or evidence 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 those codes.  There was no fracture, nonunion 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, and considering all of the evidence, the panel recommends a separately unfit determination with a disability rating of 10% for the left knee condition, coded 5099-5003 (degenerative arthritis).

Right Knee.  The panel first considered if the right knee condition, having been decoupled from the bilateral rating, met the threshold for separate rating.  The right knee was not profiled, but was implicated in the commander’s statement.  The MEB did not specifically name the right knee as failing retention standards, but rather listed “CHRONIC LEFT KNEE PAIN.”  There was no specific right knee performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  Therefore, members agreed the right knee condition was not reasonably justified as separately unfitting.  After due deliberation, the panel concluded the preponderance of performance related evidence showed the right knee condition to be not unfitting and so no additional disability rating is recommended.

Contended PEB Condition:  Tobacco Habituation.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended tobacco habituation, the panel unanimously recommends no change from the PEB determination as not unfitting, and not compensable or ratable.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20161014, w/atchs
Exhibit B.  Service Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear Applicant:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01444.

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,

		

Attachment:
Record of Proceedings