RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-02864
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20090707

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Personnel Specialist, medically separated for “bilateral patellofemoral pain syndrome [PFPS]” 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 - 20090313	VARD - 20100630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral PFPS	5099-5003	10%	Left Knee Strain	5260	10%	20100510	
Right Knee Patellar Chondromalacia	Cat II	Right Knee Strain [Surgical Residuals]	5260	10%		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 80%	
	
ANALYSIS SUMMARY:

Bilateral Knee PFPS. The PEB combined the right and left knee conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) 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 adjudicated by the PEB.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed right knee pain with running in 2006 and then later left knee pain (although a 2005 entry suggested preceding chronic bilateral pain). Arthroscopy of the right knee in August 2007 demonstrated chondromalacia patella (damage to the cartilage under the knee cap) that was debrided (chondroplasty). Both the operative note and a subsequent MRI (8 months before separation) confirmed the absence of any ligamentous or meniscal pathology. Post-operative STR entries documented persistent right knee pain and stiffness. There was ample documentation of measured range of motion (ROM) of the right knee after initial surgical recovery. These recorded flexion ranging from 75 to 110 degrees (normal 140) and extension from minus 5 degrees to 0 degrees (normal), with specific notations of painful motion. Manipulation under anesthesia in December 2007 resulted in improving ROM, and later entries consistently noted flexion to 130 degrees and 0 degrees extension. Provider entries in the STR were addressed primarily at the right knee, with some collateral mention of left knee pain and findings, but there were no entries addressing left knee pain as a primary complaint.

The 10 February 2009 MEB NARSUM examination, 5 months prior to separation, documented a history of pain in both knees “right greater than left;” although, it implied that the current severity and limitations were attributed primarily to the right knee. The CI complained of persistent pain rated 7/10, associated with subjective “locking” and “giving out,” that rendered her unable to “run, jump, kneel, or participate in any of the activities of her rate.” The physical examination recorded a normal gait and the bilateral absence of effusion, joint line tenderness, instability, or meniscal impingement. No ROM measurements or assessments were provided, although it was noted that there was a “3-degree flexion contracture” on the right with none on the left, and “pain worse with flexion, particularly on the right.” The MEB forwarded “chondromalacia of patella” for PEB adjudication without specifying whether it was bilateral. The single limited duty board (LIMDU) in evidence was for “chondromalacia right knee.” The commander’s non-medical assessment referenced only the LIMDU status without specifying a medical diagnosis.

The 10 May 2010 VA Compensation and Pension (C&P) examination, 10 months after separation, documented nonspecific bilateral knee pain with no differentiation of right versus left severity. The CI reported “severe weekly” flares with subjective locking and giving way for both knees and constant use of bilateral knee braces. The examiner noted functional limitations with prolonged walking, standing, sitting, and stairs. The physical examination (all findings bilateral) recorded a normal gait, tenderness, no effusion, no instability, and no meniscal impingement. Measured ROM was flexion to 85 degrees right and 125 degrees left and bilateral extension of 0 degrees, specifying painful motion but no ROM degradation with repetition for each knee. Of probative value note, the VA examiner expressed an opinion that the “examination yielded unreliable/inconsistent results.”

The panel directed attention to its recommendations based on the above evidence. The PEB’s consolidated rating was under criteria of code 5003 without elaboration. The panel agreed that the PEB’s Category II (conditions that contribute to the unfitting condition) diagnosis as charted above was intrinsic to the rated condition such that a separate rating could not be supported without violation of VASRD §4.14 (avoidance of pyramiding); thus, it was appropriately subsumed in the same rating. The VA rated each knee separately at 10%, both coded 5260 (limitation of flexion), based on the C&P examination and citing painful motion in support of each rating.

The panel first addressed whether each knee was reasonably justified as separately unfitting per the above standard. The evidence made clear that the right knee was associated with significantly more disability than the left one in this case. The disparity was such that the question was raised of whether the left knee could be reasonably justified as separately unfitting. Ultimately panel members concluded that it could not. Although there was left knee pain that was acknowledged in the NARSUM and included in the PEB adjudication, the LIMDU was solely for the right knee and arguably the sole basis for the MEB referral. The left knee was not implicated by the commander and was not specified in the MEB submission. Only the right knee required surgery, and it was the focus of all STR provider notes. The left knee was not clinically active for a protracted period prior to separation, and there was no performance-based evidence for any significant functional impairment attributed to it. It could thus be logically concluded that the left knee in itself would not have triggered DES proceedings and medical separation.

Having agreed that only the right knee was separately unfitting and subject to service rating, the panel deliberated the appropriate rating IAW VASRD §4.71a. The panel noted that a minimum 10% rating was obligatory as above, but also agreed there was satisfactory evidence of painful motion to support a 10% rating IAW VASRD §4.59. There was no evidence for minimum compensable ROM limitation (codes 5260 or 5261), persistent effusion and locking (code 5258), or fracture with nonunion or malunion (code 5262) to support a higher 10% rating. There were no other criteria in evidence to support a rating higher than 10% under any applicable VASRD
§4.71a code. After due deliberation, considering all evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the right knee under code 5099- 5014 (analogous to osteomalacia).

BOARD FINDINGS: In the matter of the PEB-combined bilateral knee condition, the panel recommends a rating of 10% for an unfitting right knee condition coded 5099-5014 IAW VASRD
§4.71a; and, agrees that the left knee condition was not reasonably justified as separately unfitting and not subject to separate disability rating. There are no other conditions within the panel’s scope of review for consideration. As the proposed new combined disability rating results in no change to the combined disability rating previously assigned, 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 20170325, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY   REFER  TO:
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 25 Jul 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.