RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-01706
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050318

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “bilateral anterior 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 - 20050121	VARD - 20051027	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Anterior Knee Pain	5099-5003	10%	Patellar Tendonitis, Left Knee 	5260	10%	20050720	
			Patellar Tendonitis, Right Knee 	5260	10%	20050720	
Right Lateral Epicondylitis	5308	Cat II	Epicondylitis, Right Elbow 	5206	20%	20050720	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Anterior Knee Pain.  The PEB combined the left and right knee conditions under a single 10% disability rating, coded 5099-5003 (degenerative arthritis).  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 CI 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.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee condition began in August 2002 after falling.  She then began experiencing bilateral knee pain, which worsened during her pregnancy, from July 2002 to April 2003. Radiographic studies in March 2004 showed normal right and left knees.  There was no surgical indication.  

At the 17 August 2004 MEB NARSUM examination, 7 months prior to separation, the CI reported the bilateral knee pain prevented running, standing for prolonged periods or marching.  Physical examination showed a normal gait.  There was bilateral knee tenderness along the quadriceps insertion and patellar tendon.  Range of motion (ROM) was 0 degrees extension (normal) to 140 degrees flexion (normal).  Painful motion was not addressed.  An orthopedic clinic addendum dated 23 November 2004, 4 months prior to separation, stated the “medical condition has not changed since the narrative summary was dictated on 21 Aug 04.”

At the 20 July 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported daily pain, weakness, stiffness, swelling, locking, instability, fatigue and lack of endurance.  Physical examination showed flexion of the right knee to 110 degrees and left knee to 120 degrees, with pain, and full extension bilaterally.  There was an additional loss of 15 degree of active flexion bilaterally, after repetition, due to increased pain, fatigue and lack of endurance.  The examiner noted crepitus with passive range of motion.

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left and right knee conditions and applied a single 10% rating, coded 5099-5003.  The VA rated each knee condition separately at 10%, coded 5260 (leg, limitation of flexion of), based on the C&P examination, citing leg flexion limited to 45 degrees.

The panel first considered if the left and right knees, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards, both were implicated by the NARSUM and the commander’s statement and both were profiled.  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 recommendations.  A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the NARSUM and VA examinations provided satisfactory evidence for painful motion or pain with use for each knee; thus, separate joint ratings are indicated IAW §4.71a.  Panel members agreed that there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  After due deliberation, and considering all the evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5099-5003.

Contended PEB Condition:  Right Lateral Epicondylitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting (Category II).  The contended condition was profiled, implicated in the commander’s statement and noted to fail retention standards.  

At the 29 March 2004 orthopedic examination the CI reported a 1-year history of right arm and lateral elbow pain which worsened with repetitive motion.  Physical examination showed tenderness over the lateral epicondyle and lateral elbow pain with resisted wrist dorsiflexion.  The CI was diagnosed with tennis elbow and treated with a right elbow strap.  

At the 17 August 2004 MEB NARSUM examination, 7 months prior to separation, the CI reported right elbow pain prevented the handling of a firearm.  Physical examination demonstrated tenderness along the lateral epicondyle, primarily along the proximal forearm musculature with increased pain with resisted wrist extension.  The examiner noted elbow ROM as 0 degrees extension (normal) and 140 degrees of flexion (normal 145).  

At the 20 July 2005 VA C&P examination the CI reported bilateral elbow pain radiating up the arms “with intermittent numbness and weakness of the hands.”  Physical examination showed right hand dominance.  Right elbow ROM testing showed flexion to 90 degrees and extension to -2 degrees.  Grip strength was 25 pounds on the right and 31 pounds on the left.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of right lateral epicondylitis favors its recommendation as an additionally unfitting condition for disability rating of 10% for painful motion, coded 5024 (tenosynovitis).   

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended right elbow condition, the panel agrees it was unfitting and recommends a disability rating of 10%, coded 5024 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Anterior Knee Pain	5099-5003	10%	
Left Anterior Knee Pain	5099-5003	10%	
Right Lateral Epicondylitis	5024	10%	
COMBINED	30%	

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01706.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.