RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00590
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Command Post Craftsman, medically separated for “bilateral knee pain” 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 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 - 20071001	VARD - YYYYMMDD or NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5003-5099	10%	Right Knee PFS	5257	10%	20080207	
			Left knee PFS	5257	10%	20080207	
Asthma	Not Unfitting	History of Asthma	6522	0%	STR	
PTSD		PTSD with History of ADHD 	9411	10%	20080211	
ADHD						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5099-5003 (analogous to 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 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 rating if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent right knee lateral release in 2003 and tibial tubercle osteotomy in August 2006.  She underwent left knee lateral release in December 2004 followed by chondroplasty in 2005.  The 14 March 2007 MEB NARSUM examination, 8 months prior to separation, recorded complaints of bilateral knee pain worsened with weight bearing, sitting and squatting.  The examiner recorded bilateral anterior knee pain with slight squatting.  At the 19 September 2007 orthopedic appointment, 1 month before separation, the examiner recorded range of motion (ROM) of hyperextension to 10 degrees bilaterally (normal 0)  and flexion to 125 degrees on the left and 132 degrees on the right (normal 140).  The knees were tender, but were “quite stable” with no effusion (fluid in the joint).  

The 7 February 2008 VA Compensation and Pension (C&P) examination, 3 months after separation, recorded complaints of constant bilateral knee pain.  The CI reported swelling with exercise and increased symptoms with stair climbing, squatting, prolonged sitting or kneeling.  Physical examination showed mild effusion behind the kneecaps, but no significant swelling.  ROM was recorded as 115 degrees for both knees with painful motion noted.  

The panel first considered whether right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were considered to fail retention standards by the PEB and were implicated by the NARSUM and the permanent profile.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with duty performance, panel members agreed that each knee was reasonably justified as separately unfitting.  

The panel next considered its rating recommendation for the separately unfitting knee conditions at the time of separation.  The PEB rated the combined bilateral knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated the knees separately at 10% each, both coded 5257 (knee, other impairment of, recurrent subluxation or lateral instability), citing “pain and limited motion.”  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) in either knee.  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) in each knee.  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, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for each unfitting knee condition, coded 5099-5003.  

Contended PEB Conditions:  Asthma, PTSD and ADHD.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  While the PTSD was profiled, the code was S2 (not significantly limiting) and the CI was considered worldwide qualified.  ADHD was not a compensable disability per DoDI 1332.38 (then in effect) and the CI had functioned successfully with PTSD for approximately a decade, with promotions and multiple awards.  None of the conditions were implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends separate disability ratings as follows: a 10% rating for the right knee condition, coded 5099-5003 IAW VASRD §4.71a and a 10% rating for the left knee condition, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended asthma, PTSD and ADHD conditions, the panel recommends no change from the PEB determinations as not unfitting.  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	
Right Knee Pain	5099-5003	10%	
Left Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, undated, w/atchs
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-2017-00590.

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

Attachment:
1.  Directive 
2.  Record of Proceedings