RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00043
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090817

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Watercraft Operator, medically separated for “patellofemoral syndrome” rated 10% for each knee, with a combined disability rating of 20%.   

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 conditions 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 - 20090511	VARD - 20091120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Syndrome	5099-5003	10%	Patellofemoral Syndrome, Right Knee	5299-5257	0%	20091021	
		10%	Patellofemoral Syndrome, Right Knee	5299-5257	0%		
Obstructive Sleep Apnea	Not Unfitting	Sleep Apnea	6847	50%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Patellofemoral Syndrome.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in May 2002 during basic training and without specific injury.  Magnetic resonance imaging (MRI) in January 2006 showed no evidence of fracture or dislocation, degenerative changes, effusion, or intra-joint foreign body.  The impression was “normal left and right knees.”  Another MRI in March 2006 showed no evidence of internal derangement bilaterally.  
At an orthopedic visit on 3 August 2007, the CI reported continued pain and worsening symptoms.  Physical examination revealed a normal gait and stance, and no tenderness, effusion, deformity or instability.  Noble’s compression (for iliotibial syndrome) elicited pain but medial patellar plica tests were negative.  The examiner noted normal right lower extremity strength and sensation and gave the CI a Synvisc (joint lubrication) injection.  He received additional right knee injections on 10 and 17 August 2007.  

During an 18 June 2008 orthopedic appointment, the CI reported continued knee pain with no relief from the Synvisc treatments.  Physical examination showed a normal gait and stance and no kneecap or joint instability.  Noble’s compression testing caused pain bilaterally, but there was no effusion, deformity, or instability; mediopatellar plica tests were negative.  The examiner noted normal knee motion with no lock or catching, but that knee joint pain was worse with weight bearing.  The CI was given a corticosteroid injection in the left knee.  At an orthopedic follow-up on 28 January 2009, 8 months prior to separation, the CI reported continued bilateral knee pain with no relief from Synvisc/steroid injections and physical therapy, and the examiner diagnosed patellofemoral syndrome.

At the physical therapy (PT) evaluation for the MEB on 17 March 2009, the CI reported constant bilateral knee pain rated at 4/10.  Range of motion (ROM) measurements showed bilateral flexion of 135 degrees (normal 140) and extension of 5 degrees (normal 0).  The examiner noted no abnormal limitations and negative Lachman’s testing.  

At the 1 April 2009 MEB NARSUM examination, 5 months prior to separation, the CI reported bilateral knee pain that interfered with military duties.  Physical examination of both knees showed no effusions, soft tissue swelling, valgus or varus or joint line tenderness.  Lachman, McMurray, pivot shift and Aspley’s testing were all negative, as were bilateral anterior and posterior drawer testing.  There was moderate patellar apprehension bilaterally with pain and patellar crepitus.  Neurological evaluation was normal for cranial nerves, deep tendon reflexes, strength, and sensory findings.  The examiner documented that ROM measurements agreed “precisely with those obtained by PT” and were normal with endpoint pain only at maximum extension.   

At the 10 October 2009 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported decreased knee pain since he had stopped running and marching.  Physical examination showed a normal gait, strength and reflexes.  Bilateral knee ROM measurements showed flexion of 140 degrees and extension of 0 degrees with no pain.  The examiner recorded that both knees were “visually normal, without bony deformity, edema, effusion, or inflammation” with “adequate supporting structures” and no instability. Bilateral knee X-rays were within normal limits.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee conditions 10% each, analogously coded 5099-5003 (arthritis, degenerative), citing painful motion.  The VA rated each knee condition 0%, analogously coded 5257 (knee, other impairment), citing no evidence of painful motion, limited motion, and no recurrent subluxation or lateral instability.  Members agreed there was no limitation of motion for either knee which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  Additionally, 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 mal union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was, however, evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee, but no higher, as adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the patellofemoral syndrome condition.

Contended PEB Condition:  Obstructive Sleep Apnea.  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 profiled as P2, with the only restriction requiring deployment to areas with reliable electrical source for continuous positive airway pressure therapy.  The contended condition was not implicated in the commander’s statement or judged to fail retention standards, and 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 patellofemoral syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended obstructive sleep apnea condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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 20161205, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180003342, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure