RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-02850
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20090726

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Aircraft Fuel System Technician, medically separated for “bilateral osteoarthritis of the knees (bilateral)” 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 - 20090115	VARD - 20090819	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Osteoarthritis of the Knees	5003	10%	Right Retropatellar Pain Syndrome	5259-5257	10%	20081010	
			Left Retropatellar Pain Syndrome	5259-5257	10%	20081010	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Osteoarthritis of the Knees.  The PEB combined the right and left knee conditions under a single disability rating, coded 5003 (degenerative arthritis) and rated 10%.  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 adjudicated by the PEB.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a long history of bilateral knee pain.  The CI underwent a right and left knee arthroscopy in 2002 and 2003, respectively, for meniscal debridement.  Bilateral knee X-rays taken in July 2008 showed moderate osteoarthritis.  The 10 July 2008 MEB orthopedic examination, 13 months prior to separation, noted complaints of bilateral knee pain.  Physical examination showed no right or left knee effusion or tenderness.  Bilateral knee flexion was 130 degrees (normal 140) and extension was 0 degrees (normal).  Painful motion was not addressed.  

During the 10 October 2008 VA Compensation and Pension (C&P) examination, 10 months before separation, the CI reported left knee pain.  Physical examination revealed an abnormal gait (limping). Right knee flexion was 120 degrees and left knee flexion was 130 degrees.  Extension was -10 degrees bilaterally.  Due to pain following repetitive motion right knee flexion was reduced to 110 degrees and left knee flexion was reduced to 120 degrees, extension was reduced to -20 degrees bilaterally, and there was fatigue, weakness, lack of endurance, and loss of coordination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5003, as described above.  The VA rated each knee condition 10%, dual coded 5259-5257 (cartilage, semilunar (meniscus), removal, symptomatic - knee, other impairment), based on the C&P examination, citing limitation of extension.

The panel first considered whether each knee condition remained separately unfitting, having been decoupled from the combined PEB adjudication.  Bilateral knees were “P3” permanently profiled and the commander’s statement did not implicate any specific medical condition; however, the MEB NARSUM implicated a [bilateral] osteoarthritis knee condition as duty limiting, and the MEB Report forwarded a [bilateral] osteoarthritis knee condition to the PEB for adjudication.  Objective clinical STR and VA evidence remained essentially equivocal to both knees without significant indication of either side being more impaired than the other.  The panel concluded there was not a preponderance of evidence in the STR which overcame the panel’s presumption that the bundled right and left knee conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right and left knee conditions at the time of separation.

The panel agreed there was no limitation of flexion or extension (5260 or 5261) to support a 10% rating for either knee based on the preponderance of STR evidence.  The panel considered the C&P examination an outlier.  The VA extension (ROM) value was much worse than the STR, and VA and orthopedic surgeon examinations.  There was no record of recurrent or interim injury or other development to explain this increased limitation.  The panel also noted there was no evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or fracture, nonunion or malunion of the femur or tibia causing a knee impairment (5255, 5262) to support a rating for either knee under those codes.  However, the 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case to render a 10% for each knee.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition, coded 5259, and the panel recommends a disability rating of 10% for the left knee, coded 5259.

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 5259 and rated 10%; an unfitting left knee condition coded 5259 and rated 10%, both 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	
Right Knee Osteoarthritis	5259	10%	
Left Knee Osteoarthritis	5259	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170427, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

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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-2017-02850.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.