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

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02121.

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,

								XXXXXXXXXX

Attachment:
Record of Proceedings 

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-02121
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Avionic Systems Instrument and Flight Control Systems Journeyman, medically separated for “bilateral patellofemoral syndrome” 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 - 20060216	VARD - 20071003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome	5099-5003	10%	DJD, Left Knee	5260-5010	10%	20070702	
			DJD, Right Knee	5260-5010	0%	20070702	
Bilateral Tendonitis, Wrists	Cat II	Bilateral Carpal Tunnel Syndrome	8599-8515	0%	20070702	
LBP Associated with Deconditioning	Cat II	Chronic Lumbar Strain	5237	NSC	20070702	
Obesity	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  The PEB combined the bilateral patellofemoral conditions as a single unfitting condition 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 bilateral patellofemoral syndrome condition is 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 began in 2003 while working on aircraft where frequent squatting and crawling was required.  No trauma or injury was reported.  At a physical therapy (PT) visit dated 15 April 2005 the CI had significant crepitus of the knees during therapeutic exercise.  X-rays of the left and right knees dated 13 July 2005 and one month later showed mild degenerative changes.  At an orthopedic clinic visit on 16 August 2005 the CI reported bilateral knee pain with occasional swelling with activities, but she denied instability of the knees.  Examination revealed no effusion of either knee.  Range of motion (ROM) measurements were 0-120 degrees (normal 0-140) each, without pain, but with crepitus (grinding sensation).  Ligaments were stable bilaterally and there were no meniscal signs.  The examiner’s impression was bilateral knee osteoarthritis.  Recommendations included weight loss, PT for quadriceps strength, and nonsteroidal anti-inflammatory drugs (NSAIDs) as tolerated.  A revised L3 profile was issued on 20 December 2005 with restrictions of no running, no mobility, and no squatting greater than four times per hour.  

The 17 January 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of bilateral knee pain.  Physical examination showed full ROMs, no laxity (negative anterior and posterior drawer, valgus and varus stress), no evidence of a meniscal tear, and discomfort to the posterior patella bilaterally with flexion and extension.  The commander’s statement dated 18 January 2006 indicated the CI was not working in her primary Air Force Specialty Code (AFSC), but was able to fill a position in the support section and was able to deploy in that section, but not in her AFSC.  The commander recommended a “return to duty” and re-training.  

At the 2 July 2007 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported bilateral knee pain.  There was bilateral crepitus and the ROM measurements were 0-110 degrees bilaterally with no pain on the right and terminal pain at 110 degrees on the left.  There was no loss of motion with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral patellofemoral syndrome condition 10%, analogously coded 5003 (degenerative arthritis) citing none of the conditions individually prevented the CI from performing her duties but taken in totality made her unfit and that rating the bilateral patellofemoral syndrome was most advantageous to her.  The VA rated the left and right knee degenerative joint disease (DJD) 10%, dual coded 5260-5010 (leg, limitation of flexion - arthritis, due to trauma substantiated by X-ray findings), based on the C&P examination, citing painful or limited motion of a major joint.  The VA rated the right knee DJD 0%, dual coded 5260-5010, based on the VA examination, citing absence of painful or limited motion of a major joint.  

The panel first determined whether the right and the left knees were individually unfit.  While the PEB indicated none of the conditions individually prevented the CI from reasonably performing the duties of her office, grade, rank, or rating, the fact is that the PEB assigned a 10% rating for the bilateral patellofemoral syndrome.  Therefore, because the CI was on profile and could not perform her primary duties, the panel determined each knee, having degenerative changes on X-rays and assessed as osteoarthritis by an orthopedic surgeon, was separately unfitting.  

However, there was no limitation of flexion or extension for either knee that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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).  Furthermore, there no was evidence of painful motion with functional loss to support a 10% rating (based on §§4.59, 4.40 and 4.45).  Use of a separate rating for each knee using code 5003 is not applicable since limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion, none of which was in evidence.  Therefore, in the absence of limitation of motion, the panel is in agreement with the PEB’s reasonable assignment of a 10% rating for “X-ray evidence of involvement of 2 or more major joints.” 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 patellofemoral condition.  

Contended Category II Conditions:  Bilateral Tendonitis, Wrists (DeQuervain’s Disease) and Low Back Pain Associated with Deconditioning.  The panel’s main charge is to assess the fairness of the PEB determination that the Air Force Category II contended conditions, which can be unfitting but are not currently compensable or ratable, were not unfitting.  No conditions were listed on the revised temporary profile due to patient confidentiality although there was a P4, U3, and L3 assigned with limitations of no lifting greater than 10 pounds, a recommendation of light duty, and a note that the CI could wear wrist splints.  The commander’s statement indicated she had been on a waiver since January 2002 for her wrist condition with increasing limitations for her back and knees (see above).  She was able to work as a support team member and could deploy in that capacity, but not in her AFSC.  

Chronic Wrist Pain.  The right-hand dominant CI reported left wrist pain began in 2001 and progressed.  She underwent surgical removal of a ganglion cyst in March 2003.  Despite occupational therapy, the pain continued.  In March 2005 the CI complained of right wrist popping and pain.  X-rays of the right wrist on 31 March 2005 were normal.  Average grip strength on the right was 71 pounds and on the left 77 pounds.  At an orthopedic clinic visit on 27 April 2005 the CI reported she was unable to put pressure on the right wrist, which also popped a lot.  On examination she had pain at the extremes of motion.  Flexion was 70 degrees and extension 65 degrees.  An arthrogram was essentially negative. 

At an orthopedic clinic visit in July 2005 an MRI of the right wrist was reported to be normal with a degenerative cyst in the trapezoid bone.  On examination there was no swelling of the wrists and no focal tenderness.  The ROM was full without pain.  Provocative testing (Watson shift, Finkelstein, and median nerve compression) was negative bilaterally.  On 6 September 2005 the CI reported right wrist pain with flexion and extension without point tenderness but with tenderness with a full ROM.  Bilateral wrist pain was significant such that she was unable to perform the duties of her AFSC.  An examination on 11 January 2006 indicated the CI developed right wrist pain compensating for the left wrist pain. There was good ROM with flexion and extension.  The examiner noted the CI was unable to do her assigned duties for 2 years.  

The MEB NARSUM examination, 4 months prior to separation, showed no upper extremity edema.  Each extremity was neurovascularly intact.  A left dorsal wrist 2 cm surgical scar was present.  ROM showed left wrist extension as 30 degrees but this measurement appears to be for flexion (for which normal would be 80); the right wrist was 40 degrees.  Extension bilaterally was 30 degrees (normal 70); left radial flexion was 10 degrees (normal 20) and right was 15 degrees; ulnar flexion bilaterally was 10 degrees (normal 45).  

At the C&P examination the CI reported numbness due to intermittent use of wrist splints.  Joints had normal ROMs.  X-rays showed no acute fractures or dislocations.  There was mild degenerative change with the scaphoid-trapezium joints bilaterally with mild subchondral sclerosis and osteophyte formation, otherwise no significant degenerative change was seen bilaterally.  

The PEB combined the bilateral wrist conditions as a single unfitting condition and determined them to be Category II conditions.  However, the CI was unable to perform the duties of her AFSC and had been on a series of profiles including the most recent U3.  Therefore, the panel determined that each wrist was separately unfitting.  However, there was no evidence of wrist ankylosis (5214) or limitation of motion (code 5215) to warrant a rating.  Therefore, in the absence of limitation of motion, which must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of motion, no rating is possible. There was also no significant X-ray evidence prior to separation of involvement of two or more major joints.  Therefore, although both wrists were unfitting, a 0% rating was the maximum available for each wrist.  After due deliberation, the panel agreed the preponderance of evidence with regard to the functional impairment of the bilateral wrist condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5099-5003 and meets the VASRD §4.71a criteria for a 0% rating for each wrist.  

Chronic Low Back Pain (LBP).  The CI developed LBP after her pregnancy and delivery.  X-rays of the lumbosacral spine dated 26 July 2005 were normal.  At a 12 September 2005 visit the examiner indicated the CI had LBP secondary to poor conditioning.  An MRI on 5 December 2005 showed L4-5 and L5-S1 mild disc bulges without significant neuroforaminal narrowing.  At the 17 January 2006 MEB NARSUM examination, 4 months prior to separation, ROM was flexion at 90 degrees (normal) and combined ROM 220 degrees (normal 240).  No specific tenderness or step off was noted.  On 1 February 2006 the CI had an acute exacerbation of LBP, which had been treated with over-the-counter medication, a narcotic, muscle relaxer, and an NSAID.  

At the 2 July 2007 C&P examination, 13 months after separation, the CI reported a specific point on her left lower back that caused her pain.  On examination there was point tenderness in the left lower back.  The ROM for flexion was 90 degrees and combined ROM was 240 degrees, all without pain and without limitation of motion.  There was no performance-based evidence from the record that the LBP significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended LBP, so no additional disability ratings are recommended.  

Contended Category III Condition:  Obesity.  Obesity is a condition that does not constitute a physical disability.  The panel therefore has no reasonable basis for recommending this condition as additionally unfitting for separation rating.    

BOARD FINDINGS:  In the matter of the bilateral patellofemoral syndrome condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral wrist condition, the panel recommends a disability rating of 0% for each wrist, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended low back condition, the panel recommends no change from the PEB determination as not unfitting.  In the matter of the contended obesity condition, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  A recommendation to change the VASRD code or disability description, when the combined rating is not modified, is not a recommendation authorized by the DoDI.  Unless an increase to a previously assigned combined rating is recommended, the Board Findings will remain a no change recommendation.  Since there is no change in the overall rating of 10%, 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 20170301, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record