RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03442
BRANCH OF SERVICE:  air force 	SEPARATION DATE:  20060711

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Security Forces Helper, medically separated for “bilateral patellofemoral syndrome” with a combined 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 - 20060601	VARD - 20070131	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome  	5099-5003	10%	Left Knee Patellofemoral Syndrome	5299-5260	10%	20061031	
			Right Knee Patellofemoral Syndrome	5299-5260	10%	20061031	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  The PEB combined the left and right knee conditions under a single 10% disability rating, coded 5009-5003 (analogous to degenerative arthritis).  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, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began in March 2006 during basic training without trauma or injury.  The bilateral knee pain was exacerbated by running, bending, prolonged standing and climbing stairs.  At the 21 March 2006 primary care clinic (PCC) right knee examination showed pain at the anterior of the knee made worse with climbing and facing movements.  Tenderness was noted, but there was no effusion, swelling, deformity, erythema or warmth, and the CI had full range of motion (ROM).  The left knee was not addressed. 

During the 20 April 2006 PCC examination, both knees showed anterior knee pain with popping, but there were no signs of locking or giving way.  The pain was made worse by climbing stairs.  The CI walked with a normal gait.  Mild tenderness was noted by the examiner along the anterior tibia.  There was no edema.  ROM was full and within normal limits.  Strength was noted as 5/5 with a negative McMurray’s test.  

At the 2 May 2006 orthopedics examination, both knees showed tenderness over the patellar tendon/tibial tuberosity.  Pain was elicited throughout ROM with extension.  A patella femoral grinding test and a patellofemoral apprehension test were both positive, but both knees were stable.  There was no swelling, induration, edema, erythema or warmth noted.  There were no signs of meniscal pathology (McMurray test).

The 9 May 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral knee pain.  Physical examination showed a strength of 4/5 in the lower extremities and tenderness over bilateral medial joint line.  McMurrays and Lachman testing were both negative.  There was pain associated with varus and valgus stress testing.  No laxity, edema, erythema, ecchymosis, crepitus or deformities were noted.  X-ray studies showed no acute abnormalities.  Final diagnosis was bilateral patellofemoral syndrome.  

At the 23 October 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported bilateral knee pain.  The CI reported weakness in the knees and episodes of giving way, which had occurred twice.  The CI also reported stiffness in the morning after prolonged standing.  Locking had occurred several times.  The CI reported the joint pain occurred 4-6 times per week and lasted about 15 minutes.  The pain was reported as aching in nature with a pain level intensity of 7/10.  Pain was elicited by physical activity and intensified with climbing.  The condition did not cause incapacitation and she was not receiving any treatment.  Functionally she was unable to walk for prolonged periods without pain.  The CI did not use any assistive devices and was employed in the same job.  Physical examination showed that the CI’s posture and gait were within normal limits.  Examination of the left knee showed no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement, but crepitus was noted.  Left knee ROM was flexion of 140 degrees (normal) and extension of 0 degrees (normal).  The joint function of the left knee was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  The anterior and posterior cruciate ligaments were within normal limits.  The medial and lateral collateral ligaments of the left knee were within normal limits.  Examination of the right knee revealed crepitus and anterior knee tenderness.  Right knee ROM testing showed 140 degrees of flexion and 0 degrees of extension.  Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  The anterior and posterior cruciate and medial and lateral collateral ligaments of the right knee were within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the left knee 10% and the right knee 10%, both analogously coded 5260 (leg, limitation of flexion), based on the C&P, citing painful motion.  Panel members considered that the objective findings and associated disability for each knee were identical.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and the commander’s statement; and, both were profiled.  Members agreed therefore that each knee should reasonably be considered separately unfitting.  

There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (5261) in either knee.  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 for either knee.  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) for either leg.  However, there was evidence of painful motion with functional loss supporting a 10% rating for each knee (based on §4.59, §4.40 and §4.45).  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition coded 5099-5003 IAW 4.71a.

BOARD FINDINGS:  In the matter of the right knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Patellofemoral Syndrome  	5099-5003	10%	
Right Patellofemoral Syndrome  	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170413, 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-2017-03442.

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.

						Sincerely,

								XXXXXXXXXXXXXXXXXX								                           Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings