RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-00245
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, Aviation Boatswain’s Mate (Handling), medically separated for “bilateral patellofemoral pain syndrome” with a disability rating of 10%.  

CI CONTENTION:  She was not give full consideration of her injuries and needed physical therapy and to pursue a new career after separation.  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 - 20031202	VARD - 20040903	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain Syndrome	5299-5003	10%	Left Patellofemoral Syndrome with Tendinitis	5014	10%	20040520	
			Right Patellofemoral Syndrome with Tendinitis	5014	10%	20040520	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Pain 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 together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee pain in June 2000 without specific injury or trauma, but worsened with “2 years stair climbing on steel deck.”  She began physical therapy and was also treated with a nonsteroidal anti-inflammatory drug, and in October 2002, X-rays showed early degenerative spurring of the tibial spines of both knees, consistent with early osteoarthritis.  A bone scan on 31 October 2002 was normal for both knees, lower legs, and ankles.  On 3 December 2002, the CI was found to have an over-pronator gait (overuse syndrome of the lower extremities), bilateral patellofemoral syndrome, and tibialis tendonitis.  She was placed in a limited duty status for what was described as “accumulative micro-trauma, overuse on flight deck, and arduous sea duty not responsive to conservative management.” On 11 February 2003, X-rays showed “perhaps minimal joint effusion on the left” and “very mild lateral patellar tilt on the right.” 

At the 26 February 2003 physical therapy appointment, 12 months before separation, the examiner reported genu recurvatum (knee bends backward) of both knees with normal knee motion, but no swelling, medial/ lateral instability, or tenderness.  Pain was elicited in both knees during a full squat and shoe inserts were issued. 

The 6 August 2003 MEB NARSUM examination, 7 months prior to separation, noted CI complaints of bilateral knee pain with an inability to run, climb, or squat.  Physical examination showed full bilateral knee range of motion (ROM), increased femoral anteversion, and peripatellar and patellar facet tenderness.  Compression (to check for meniscal injury) and inhibition (to check for patellofemoral syndrome) tests were positive and she was unable to squat due to anterior knee pain.  During the 28 August 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported numbness and tingling when kneeling, standing, or squatting, as well as aching when running for a long period.  She also had pain at rest, knee weakness, and heaviness after exertion.  Physical examination recorded chronic patellofemoral syndrome in both knees.  

At the 20 May 2004 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported bilateral knee pain and tendonitis that interfered with her ability bend, stoop, run, jump, stand for prolonged periods, or participate in sports.  Physical examination showed a normal gait and bilateral ROM from 0-140 degrees (normal), with no pain.  Drawer’s testing (to determine instability) was normal bilaterally, but McMurray’s testing (to determine meniscal tear) was slightly positive on the left and normal on the right.  There was no evidence of any recurrent subluxation, locking pain, joint effusion, or crepitus. 

The panel first considered if each knee condition, when decoupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were considered to fail retention standards and were implicated in the NARSUM.  The non-medical assessment and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with duty performance, members agreed that each knee was reasonably justified as separately unfitting.  
The panel then considered its rating recommendation for each knee based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5299-5003 (arthritis, degenerative).  The Navy PEB also listed “resolving medial tibial stress syndrome” as a related Category II condition (contributes to the primary unfitting condition but was not separately ratable), which the panel agreed was properly subsumed under the overall rating for the “bilateral patellofemoral pain syndrome” IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the right knee and left knee conditions 10% each, both coded 5014 (osteomalacia), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  Members considered that the objective findings and associated disability for each knee were nearly identical, and adjudged that the respective ratings should therefore be the same.  There was no limitation of flexion or extension that supported a rating under codes 5260 or 5261; 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); and 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as reflected on the NARSUM examiner’s notation that the CI was unable to squat secondary to bilateral anterior knee pain.  The same limitation was noted by the physical therapist in February 2003.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition and 10% for the right knee condition, both coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral patellofemoral pain syndrome, the panel recommends a disability rating of 10% for the left knee and 10% for the right knee, both coded 5099-5003 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Patellofemoral Pain Syndrome	5099-5003	10%	
Right Patellofemoral Pain Syndrome	5099-5003	10%	
COMBINED	20%	

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve A£fairs) COMMANDER, NAVY PERSONNEL COMMAND
Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS 
Ref:	(a) DoDI 6040.44
(b)	PDBR ltr dtd 09 Oct 18 ICO XXXXXXXXXX

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

a.	XXXXXXXXXX: Entitlement to disability separation pay with a 20 percent disability 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.