RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02316
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Tactical Aircraft Maintenance Craftsman, medically separated for “chronic bilateral knee pain” and “chronic low back pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “I received a 70% disability rating from the VA within 9 months of my discharge from the Air Force.  Please 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 - 20050126	VARD - 20051212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5003-5099	10%	Left Knee Osteoarthritis	5003-5260	10%	20051121	
			Right Knee Osteoarthritis	5003-5260	10%	20051121	
Chronic Low Back Pain	5237	10%	Lumbar Spine Mild Osteoarthritis with Disc Bulge	5242	20%	20051121	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the left and right 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 left and right knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

The panel first considered if each knee condition, having been de-coupled from the combined PEB bilateral knee adjudication, remained separately unfitting as established above.  Members noted that the CI’s physical profile had significant restrictions including no prolonged standing or walking “due to knee derangement.”  The commander referenced the CI’s knees as a basis for his duty limitations, without specifying one or both knees.  The panel concluded there was not a preponderance of evidence in the STR which overcame the panel’s presumption that each knee condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting knee conditions at the time of separation.

Left Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent a left knee arthroscopy with debridement of the posterior horn medial meniscus on 1 December 2003.  After initially doing well, the CI began to have significant knee pain and additional therapy did not allow for unrestricted duty.  The left knee condition was not examined during the MEB NARSUM in April 2004.  A subsequent MEB addendum, signed initially on 20 July 2004 and again on 23 November 2004, stated that the CI had suffered from bilateral knee pain since April 2003 and noted that his bilateral knee symptoms were stable but the condition was chronic.  No examination was conducted.  

At the 21 November 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported left knee pain that was exacerbated by squatting, kneeling, climbing or descending stairs, or walking more than a mile.  He denied locking, swelling, or giving out.  Physical examination showed a steady gait with no heat, swelling, redness, or deformity of the knee.  Left knee range of motion (ROM) measurements were flexion of 120 degrees (normal 140) and extension of 0 degrees (normal) with no mention of painful motion.  The bilateral knee X-rays were contradictory.  The “findings” section showed “osteoarthritis,” but did not cite the findings that substantiated that diagnosis and the “impression” section showed “negative bilateral knees.”  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left and right knees and applied a single 10% rating coded 5003-5099 (analogous to degenerative arthritis).  The VA rated the left knee condition 10%, dual coded 5003-5260, (degenerative arthritis-limitation of flexion of the leg), based on the C&P evaluation.  Members noted there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261), and no evidence of painful motion with functional loss 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); and 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).  However, the persistence of pain after meniscal surgery warranted a 10% rating under the 5259 code (cartilage, semilunar, removal of symptomatic).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition, coded 5259.  

Right Knee Pain.  According to the STR and MEB NARSUM, the CI’s right knee condition began in April 2003 with no specific trauma or injury noted.  At the 24 November 2003 family practice appointment he reported his right knee felt the same as his left knee, which was diagnosed with a torn meniscus.  MRI studies in January 2004 showed no evidence of meniscal tears and reflected an essentially normal right knee other than a very subtle area of signal alteration that may have represented an area of articular cartilage thinning.  At the 4 March 2004 orthopedic visit, the CI reported right knee pain that was localized mostly to the medial joint line, with locking and popping.  He was unable to squat.  Physical examination showed no effusion.  The CI had flexion to 140 degrees and extension to 0 degrees with no mention of painful motion.  Weight-bearing X-rays taken that day were normal with no evidence of arthritis.  The MEB addendum, signed initially on 20 July 2004 and again on 23 November 2004, stated that the CI had suffered from bilateral knee pain since April 2003 and noted that his bilateral knee symptoms were stable but the condition was chronic.  No examination was conducted.  

At the 21 November 2005 C&P evaluation the CI reported his right knee felt the same as the left knee.  He stated it locked once a month or so and more frequently if he was bending it more, but he denied it giving out.  Pain was exacerbated by squatting, kneeling, climbing or descending stairs, and walking more than a mile.  Physical examination showed a steady gait with no heat, swelling, redness, deformity or tenderness.  Measured ROM was flexion 120 degrees and extension 0 degrees with no mention of painful motion or guarding.  Bilateral knee X-rays were contradictory.  The “findings” section showed “osteoarthritis,” but did not cite the findings that substantiated that diagnosis and the “impression” section showed “negative bilateral knees.”  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right knee with the left knee and applied a single 10% rating coded 5003-5099.  The VA rated the right knee condition 10%, coded 5003-5260 (limitation of flexion of the leg due to degenerative arthritis) based on the C&P evaluation.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 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).  No additional functional limitation was evidenced by the examinations.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than 0%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right knee condition, coded 5299-5003.  

The panel noted that the combination of the 10% rating for the left knee and the 0% rating for the right knee did not constitute a rating advantage for the CI.  Therefore, after due deliberation, considering all of 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 bundled bilateral knee conditions.  

Chronic Low Back Pain (LBP).  According to the STR and MEB NARSUM, the CI’s LBP condition began in 1998 or 1999 with no specific trauma or injury.  At the 4 March 2004 neurological appointment, he complained of worsening pain radiating down his leg for about a 4-week period.  The examiner did not provide specific ROM measurements, but reported he was able to flex forward to within 3 inches of the floor and had normal back extension, lateral tilt, and straight leg raising.  He also reviewed an MRI (not in evidence) which he described as “totally normal” and recommended against surgery.  A subsequent MRI conducted on 13 May 2004 showed a bulging disc but no evidence of herniation or other abnormality.  The radiologist noted that this finding was unchanged from a prior study on 15 September 2003.  
The 26 April 2004 MEB NARSUM examination, 11 months prior to separation, noted CI complaints of constant LBP exacerbated by prolonged sitting or standing, bending at the waist, squatting, lifting or running, but he denied weakness or numbness.  A detailed physical examination of the back was not conducted.  

At the 21 November 2005 C&P evaluation the CI reported pain in his lower back which was worsened by squatting, kneeling, climbing or descending stairs, or walking more than a mile.  Physical examination revealed a normal gait with tenderness at L4-5 level and decreased lumbar lordosis.  The examiner was silent regarding muscle spasm or guarding.  Thoracolumbar ROM measurements showed forward flexion of 85 degrees (normal 90) and combined ROM of 205 (normal 240) with painful motion noted at the end of flexion.  X-ray studies revealed L5-S1 spondylolysis and generalized mild osteoarthritis with no mention of an abnormal spinal contour.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbosacral strain).  The VA rated the LBP condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P evaluation, citing decreased lumbar lordosis.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees and/or combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on the VA examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of 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 LBP condition.  

BOARD FINDINGS:  In the matter of the bundled bilateral knee conditions and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the LBP 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-2017-02316.

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