RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01917
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080321

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Personnel Craftsman, medically separated for “chronic bilateral knee pain” with a disability rating of 10%. 

CI CONTENTION:  Review of all conditions requested.  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 - 20080114	VARD - 20080821	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Right Knee Patellofemoral Syndrome	5299-5024	0%	20080528	
			Left Knee Patellofemoral Syndrome	5299-5024	0%	20080528	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  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 of the PEB.  The evidence for the right and left knee conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began insidiously in approximately June 2000, but X-rays at the time were normal.  An MRI of the right knee in February 2007 showed a mild inflammatory change of the tibial insertion of the patellar tendon with adjacent subcutaneous edema and chondral (cartilage) abnormalities at the articular surface of the patella, including a 7 mm partial thickness defect at the median patellar ridge.  An MRI of the left knee showed mild tendinosis of the patellar tendon with mild adjacent subcutaneous edema.  There were no chondral defects and no discrete tear of the posterior horn of the medial meniscus or a displaced fragment.  

At a physical therapy (PT) clinic visit on 18 May 2007 the CI indicated she was told she was not a surgical candidate.  X-rays of both knees dated 25 May 2007 were negative.  The CI received a series of hyaluronate injections to the right knee beginning 25 May 2007 through 8 June 2007 and was prescribed knee braces.  At a physical medicine and rehabilitation clinic visit on 18 June 2007 the CI reported continued pain and an inability to run despite medication and PT, although she reported about 50% relief with the hyaluronate injections to the right knee.  Continued stretching, appropriate squatting, and hyaluronate injections to the left knee were recommended for the bilateral patellofemoral syndrome.  At the 16 July 2007 PT range of motion (ROM) study, 8 months prior to separation, left and right flexion and extension were normal, but the CI did have pain with squats bilaterally and tenderness bilaterally at the pes anserine of the anterior, medial proximal tibia and medial and lateral joint lines.  

The 3 December 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of right greater than left knee pain.  Physical examination showed a normal gait without guarding, normal movement of the extremities after four repetitions, and no erythema, swelling, or effusion in either knee, but there was patellar tenderness and crepitus (grinding) bilaterally.  Both knees were ligamentously stable to varus and valgus stress.  On 11 December 2007, at the primary care clinic, the examiner recorded the ROM was preserved for the bilateral knees and there was no effusion, warmth or erythema.  However, the patellae were hypermobile and there was tenderness upon pressure of the patella over the femoral groove. 

At the 28 May 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported 7/10 bilateral knee pain with stiffness, swelling, giving way, and locking, all of which affected her ability to walk or run for prolonged periods.  The CI denied weakness, heat, redness, lack of endurance, fatigability, or dislocation in either knee.  Physical examination showed a normal gait without signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement bilaterally.  There was crepitus, but no genu recurvatum or locking pain in either knee.  The ROM measurements were 140 degrees (normal 140) of flexion and 0 degrees (normal 0) of extension bilaterally.  The joint function for either knee was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  Provocative testing showed both knees to be ligamentously stable. 

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).  The VA rated the right and left knee conditions 0% each, analogously coded 5299-5024 (tenosynovitis), based on the C&P examination, citing no evidence of painful or limited motion of a major joint.
The panel first considered if the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the right and left knee conditions contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings are recommended.

There was no limitation of motion for either knee which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There likewise was no evidence of painful motion with functional loss for either knee supporting a 10% rating (based on §§4.59, 4.40 and 4.45).  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 for either knee 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) for either leg.  No additional functional limitation was evidenced by the examinations.  However, there was MRI evidence of pathology in both knees supporting a 10% rating under the provisions of VASRD code 5003 consistent with the 10% PEB rating.  Therefore, the panel majority concluded there was not sufficient evidence to support a rating higher than the 10% adjudicated by the PEB for the bilateral knee condition.  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 chronic bilateral knee condition.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 20% (10% for each knee) and did not elect to submit a minority opinion.  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 20170215, 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-2017-01917.

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,

		

								

Attachment:
Record of Proceedings