RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01550
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Airborne Battle Management Systems Weapons Director, medically separated for “bilateral osteoarthritis of the knees” with a  disability rating of 10%.  

CI CONTENTION:  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040105	VARD – 20050725	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Osteoarthritis of the Knees	5003	10%	Patellofemoral Pain Syndrome with Traumatic Arthritis, Left Knee	5260-5010	10%	20050701	
			Patellofemoral Pain Syndrome with Traumatic Arthritis, Right Knee	5260-5010	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Osteoarthritis of the Knees.  The PEB combined the right and left knee conditions under a single disability rating, coded 5003 (arthritis, degenerative) 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 necessarily 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.  

According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI initially injured his right knee in a vehicular accident in 1999 (over 5 years before separation); and, this followed a complicated clinical course.  Both meniscal and anterior cruciate ligament (ACL) damage was identified and resulted in multiple (7) surgical interventions.  These included meniscal repair, ACL reconstruction, multiple ACL revisions and a repeat graft reconstruction, and arthroscopic debridement with lateral retinacular release for patellofemoral pain syndrome (PFPS).  One of the latter, performed 24 June 2003 (~11 months before separation), was the last surgical intervention by the service.  MRI demonstrated intact menisci (some degenerative changes but no tears), intact ligaments (post-operative changes for ACL), and mild joint arthritis without further pathology.  

An atraumatic onset of left knee pain was documented in an orthopedic note in July 2002 (20 months before separation), although most STR entries were directed at the right knee.  MRI demonstrated some “mild” meniscal degenerative changes with no other abnormality, and the diagnosis was PFPS.  An arthroscopic debridement with lateral retinacular release (the only left knee surgery) was performed 28 January 2003 (9 months before separation).  Of note, MEB for the right knee was well underway and the NARSUM (below) was completed prior to the left knee surgery.  Nevertheless, all of the later STR entries referenced bilateral knee pain and a final entry on 15 January 2004 (4 months before separation) stated “doing well with his patellofemoral symptoms,” and “a little more symptomatic on the right than the left.”  

There were multiple entries throughout the STR that provided range of motion (ROM) measurements for the right knee.  All of them documented extension to 0 degrees (normal), with the exception of one that noted minus 2 degrees (minus 10 degrees for minimum 10%).  Measured flexion ranged from 100 to 140 degrees (normal 140, 45 for minimum 10%), with the majority of evidence in the normal or near normal range.  The measurements most proximate to separation (6 months prior) were from a physical therapy entry of 3 December 2003 that recorded extension 0 degrees and flexion to 139 degrees.  There were multiple other entries that noted grossly normal ROM with the single exception of aeromedical evacuation notes in October 2002 that recorded “limited” and “severely limited” observed ROM.  The single documentation of measured ROM for the left knee (13 months before separation) was extension 0 degrees and flexion to 139 degrees, although there were several other entries that documented grossly normal bilateral ROM.  There was consistent STR documentation of a gait disturbance favoring the right knee.  There were no STR entries that documented persistent effusion, locking, significant instability, or any other VASRD-ratable findings for either knee.

The 16 July 2003 NARSUM examination, 10 months prior to separation, documented a MEB referral for bilateral knee pain.  The examiner noted persistent non-specific pain that was controlled on medication (anti-inflammatory plus rescue narcotic), with no mention of other related symptoms or elaboration of functional limitations.  The physical examination recorded “gait limping on the right side,” well healed scars, normal (5/5) muscle strength (no mention of atrophy), bilateral crepitus with motion; and, although there was difficulty with full extension on the right, bilateral ROM was characterized as “full.”  Neither the NARSUM nor any of the STR entries documented painful motion for either knee, although it was not directly addressed or refuted.  The NARSUM made no note of effusion, instability, or impingement (locking) for either knee.

The MEB’s DD Form 2697, Report of Medical Assessment, was dated 1 April 2004 (5 weeks before separation) and documented the following ROM evidence: right knee flexion to 110 degrees and extension of minus 15 degrees; and, left knee flexion to 120 degrees with “full” extension.  No other physical findings were provided and painful motion was not addressed.  Given the gross characterization of left knee extension, it could not be fully ascertained whether these were ROM measurements or visual estimates.  The single AF Form 618 MEB submission, as reflected by the PEB adjudication, was for a bilateral condition.  Neither the profile nor the commander’s performance statement provided evidence probative to separate fitness implications of either knee.

The 1 July 2005 VA Compensation and Pension (C&P) evaluation, 14 months after separation, documented a complaint of constant pain and stiffness without note of additional symptoms (swelling, locking, instability, etc.), and without elaborating severity or specific functional limitations.  It was noted that the CI had been employed since separation as a restaurant manager.  The physical examination recorded a normal gait, tenderness on the right but not the left, bilateral crepitus; and, no effusion, ratable instability or impingement for either knee.  Measured ROM was bilateral extension of 0 degrees, right flexion to 135 degrees, and left flexion to 120 degrees; annotating pain at the limits for both knees and no ROM degradation with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s bilateral 10% rating under criteria of code 5003 did not cite a rationale.  Each of the VA’s separate 10% ratings under code 5260-5010 (limitation of flexion and traumatic arthritis) cited painful motion.  Although the PEB’s bilateral rating complied with the 10% criterion of “2 or more major joints” for code 5003 under VASRD §4.71a, the application of code 5259 (cartilage, semilunar, removal of, symptomatic) was readily justified for the right knee only, and provides for a 10% rating independently of any other criteria.  Therefore the pairing of joints under 5003, given that one was separately ratable, was of dubious validity.  Nevertheless, the panel must still justify each knee as separately unfitting (as elaborated above) in order to recommend separate ratings.  

Members agreed that the right knee was well justified as separately unfitting, with the multiple surgeries and as the cause for the limping gait present at separation.  The panel deliberated, however, whether the left knee was likewise justified.  Although it could not be established with certainty that the left knee in itself would have prompted MEB referral and prohibited further service, members agreed that it would be unfairly speculative to conclude that it would not have.  The fact remained that the left knee was severe enough to require surgery; and, judging by the STR entries after that surgery, the severity rivaled that of the right knee.  Even if the left knee made a significant contribution to unfitness via combined effect, it would still merit separate rating.  Members therefore concluded that the left knee was reasonably conceded as separately unfitting, and that each joint merited service rating.

Having so agreed, members turned to deliberation of the appropriate coding and rating recommendation for each knee.  As already stated, a minimum 10% rating for the right knee was justified under code 5259.  Members agreed that the isolated evidence for reduction of extension to 15 degrees (ratable at 20% under code 5261) as noted in the MEB medical examination was insufficiently probative given all of the contrary evidence.  There was thus no evidence for compensable ROM limitation, persistent effusion and locking, or instability to merit a higher rating under any other applicable joint code.  

Members deliberated whether the severity and functional limitations attributable to the right knee merited analogous rating under 5299-5262 (tibia and fibula, impairment of) which confers ratings for contiguous knee disability: 20% for “moderate” and 30% for “marked.”  Members agreed, however, that rating analogously for moderate disability was not sufficiently justified.  The most significant functional limitation in evidence was the gait disturbance still present at the time of the NARSUM, and the C&P indicated that it would have logically been resolving approaching separation.  It was thus not clear if the gait disturbance was significant or even present at the time of separation, and the C&P indicated there was not significant occupational impairment by that time.  Members thus agreed that the right knee was fairly rated at 10% under code 5259.

The panel next deliberated the appropriate coding and rating for the left knee.  Under the criteria elaborated above for the right knee there was no evidence in support of a rating higher than 10% for the left knee, with no justification for analogous rating via 5299-5262.  Justification of the minimum compensable rating (10%), in fact, required concession to VASRD §4.59 (painful motion); but, members agreed that it was fair to concede painful motion.  No service examiner directly addressed painful motion, but it likely existed given the C&P documentation that it was still present even though the overall course was improving.  Members therefore concluded that the left knee was fairly rated at 10%, proposing code 5099-5024 (analogous to tenosynovitis) for its clinical compatibility with the diagnosis of PFPS.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends separate ratings for each knee: the left one rated 10% under code 5259, and the right one rated 10% under code 5099-5024.

BOARD FINDINGS:  In the matter of the bilateral osteoarthritis of the knees 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 5099-5024 and rated 10%, both IAW VASRD §4.71a and §4.59.  There are 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	
Multiple Surgical Residuals, Right Knee 	5259	10%	
Patellofemoral Pain Syndrome, Left Knee 	5099-5024	10%	
COMBINED	20% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161020, w/attachments
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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01550.

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.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

2 Attachments:
1.  Directive
2.  Record of Proceedings