RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01475
BRANCH OF SERVICE:  air force	SEPARATION DATE:  20071202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Communication Computer Systems Planning and Implementation Craftsman, medically separated for “bilateral knee pain, patellofemoral syndrome with pes anserine bursitis” 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 - 20070925	VARD - 20081021	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Right Knee Condition	5260	NSC	20080624	
			Residuals, Left Knee Patellofemoral Syndrome	5257	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY: 

Bilateral Knee Pain, Patellofemoral Syndrome with Pes Anserine Bursitis.  The PEB rated the bilateral knee condition 10% under a single disability rating, analogously coded 5003 (arthritis, degenerative).  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 of the PEB.  The evidence for the bilateral knee pain is presented together for brevity, 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 reported ongoing bilateral knee pain for years.  Bilateral knee X-rays and MRIs were unremarkable or normal.  There was no surgical indication.  The family practice examination on 30 March 2007, 8 months before separation, noted complaints of bilateral knee pain.  Physical examination revealed no bilateral knee swelling, and stability and meniscus testing were negative.  Bilateral knee range of motion (ROM) was full and painful motion was not addressed.  There was right knee tenderness, crepitus, and popping with flexion and extension.  At the orthopedic clinic on 24 May 2007, 6 months before separation, physical examination revealed no bilateral knee swelling or instability, but tenderness was present.  Again, ROM was full and painful motion was not addressed.  

At the 13 July 2007 MEB NARSUM examination, 5 months prior to separation, the CI reported chronic bilateral knee pain that popped and gave out; aggravated by running, bicycling, jumping, and prolonged standing.  Physical examination was performed by the aforementioned family practice physician at 8 months before separation.  A physical therapy examination on 03 August 2007, 4 months before separation, revealed right knee ROM of extension to 0 degrees (normal) and flexion was 155 degrees (normal 140).  Left knee ROM was extension to 0 degrees and flexion was 156 degrees; bilateral painful motion was present.  

During the 24 June 2008 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported constant-chronic bilateral knee pain with weakness, stiffness, give way, and locking; that was aggravated by physical activity.  Physical examination revealed an abnormal, slow gait.  There was no bilateral knee swelling, tenderness, locking, or crepitus; stability testing was negative.  Bilateral knee ROM was normal, with no comment of painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing DOD and VASRD guidelines.  The VA rated the left knee condition 10%, coded 5257 (knee, other impairment), based on the C&P examination, citing slight left knee laxity.  The VA did not service connect the right knee condition, coded 5260 (leg, limitation of flexion), citing no permanent residual or chronic disability subject to service-connection was shown by the evidence following separation.  

The panel first considered if the right knee and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The CI was issued a temporary L4 physical profile that did not specify a medical condition; however, the CI was limited from running and performing ERGO (stationary bicycle fitness test).  The commander’s statement implicated the CI’s “arches and knee complications” as duty limiting.  The MEB NARSUM and Medical Board Report both judged the bilateral knee condition to fail retention standards.  The objective clinical and radiologic evidence proximate to separation remained essentially equivocal to both knees without significant indication of either side being more impaired than the other.  The panel concluded there was not a preponderance of evidence in the STR which overcame the panel’s presumption that the bundled right and left knee conditions were reasonably considered separately unfitting.  

The panel then considered its rating recommendation for the unfitting right and left knee conditions.  The panel agreed there was no limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261) for either knee.  There was no objective evidence of painful motion with functional loss based on the preponderance of STR or VA evidence to support a 10% (based on VASRD §§4.59, 4.40 and 4.45) for either 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 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 bilateral knee condition.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2017-01475.

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,

	

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings