From:
To:

Subj: Ref:

Director, Secretary of the Navy Council of Review Boards
PD-2017-02197

PHYSICAL DISABILITY BOARD OF REVIEW (PDBRJ

(a) DoDI 6040.44
(b) PDBR ltr of 12 Aug 19

IN REPLY REFER TO

1850
CORB:003
27 Feb 20

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its
recommendation to the Department of the Navy for appropriate action.

2.	On 21 February 2020, the Assistant General Counsel of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEBJ from 0% to 10% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the Deputy Commandant, Manpower and Reserve Affairs, for appropriate changes to your personnel records and notification to you upon completion.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-02197
BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20050701

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Rifleman, medically separated for “patellofemoral pain syndrome [PFPS]” with a disability rating of 0%.

CI CONTENTION: “Not all conditions were rendered together when they are all reasons for discharge.”  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 – 20050407	VARD - 20051128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PFPS	5099-5003	0%	Chondromalacia, Left Patella	5099-5003	0%	20060131	
			Chondromalacia, Right Patella	5099-5003	0%		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 0%	

ANALYSIS SUMMARY:

PFPS. The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 (arthritis, degenerative) and rated 0%. 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. 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’s bilateral knee condition began in November 2003 after returning from a 7-month deployment. He initially sought treatment for left knee pain, but imaging, including an MRI, was normal. At an orthopedic examination on 22 October 2004, the CI reported left knee pain, greater than right, for a year. The provider diagnosed bilateral PFPS, and recommended conservative treatment rather than surgical intervention.

At a physical therapy examination on 30 November 2004, the CI reported bilateral PFPS with recently increased left knee pain, “popping,” swelling, and giving way. Physical examination of both knees revealed anterior knee pain with single leg squats, and near full hamstring and quadriceps strength with minor pain on testing. Knee ROM showed 4 degrees of hyperextension bilaterally, and flexion to 130 degrees on the left, and 135 degrees on the right.

At the 2 December 2004 MEB NARSUM examination, 7 months before separation, the CI reported chronic bilateral knee pain that limited his ability to hike, run, walk for long distances, or sit/stand for long periods. Left knee pain had been present for 12 months and right knee pain for 4 months. Physical examination revealed positive left and negative right patellar compression tests, and positive bilateral patellar grind and crepitus with hypermobility. Gait was guarded with normal mechanics, and there was no effusion, joint line tenderness, instability, or meniscal pathology. Measured bilateral knee range of motion (ROM) showed flexion of 135 degrees (normal 140) and extension of 0 degrees (normal) following repetitive movement. The MEB NARSUM examiner determined the CI fell below retention standards due to bilateral PFPS. The 26 January 2005 non- medical assessment, 5 months prior to separation, implicated both knees as impairing duty performance. The commander stated the CI “cannot perform any duty that requires him to use his legs.”

At the 31 January 2006 VA Compensation and Pension (C&P) examination, 7 months after separation, he reported right and left knee patella chondromalacia. Physical examination of the knees revealed normal gait, posture and coordination, with no swelling, effusion, ankylosis, redness or heat. There was left knee tenderness and crepitus with movement (greater on the left than right), but no laxity of either joint. Strength was normal and both knees had full ROM with pain on flexion and extension against resistance on the left only.  Knee X-rays were normal.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB rated the bundled right and left knee conditions 0%, coded 5003. The VA rated the left knee condition 10%, and the right knee condition 0% each, coded 5003, based on the C&P examination, citing painful left knee motion. Panel members first considered whether each knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. In this case, both knees were implicated by the commander’s statement and failed retention standards. Although STR notes indicated the left knee was worse than the right, undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with military specialty performance. Therefore, the panel agreed that each knee was reasonably justified as separately unfitting.

Although there was no compensable limitation of flexion or extension (5260, 5261), there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the left knee, but not the right knee, at the VA examination. There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); history of surgery to remove a meniscus (5259); or fracture, nonunion or malunion of either femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262). Thus, there were no higher ratings than 10% for left knee and 0% for the right knee supported under any applicable codes. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends left PFPS, rated 10%, and right PFPS rated 0%, both coded 5099-5003.

BOARD FINDINGS: In the matter of the patellofemoral pain syndrome, the panel recommends that each joint be separately adjudicated as follows: unfitting left patellofemoral pain syndrome rated 10%, and unfitting right patellofemoral pain syndrome rated 0%, both coded 5099-5003 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, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Patellofemoral Pain Syndrome	5099-5003	10%	
Right Patellofemoral Pain Syndrome	5099-5003	0%	
	COMBINED	10%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170227, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record