RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04394
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Air Transportation Craftsman, medically separated for “patellofemoral syndrome” with a disability rating of 10%.   

CI CONTENTION:  His VA rating was 60% when he was separated from service and he believes he should have been medically retired.  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 - 20041006	VARD - 20050624	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Syndrome	5099-5003	10%	Left Knee Arthritis	5010	10%	20050429	
			Left Knee Laxity	5257	10%	20050429	
			Residuals of Right Knee ACL Repair	5299-5259	10%	20050429	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Patellofemoral Syndrome.  The PEB combined the right and left 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 is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent right knee surgery with anterior cruciate ligament (ACL) reconstruction in April 2003, and multiple left knee surgeries in the 1990s to include high tibia osteotomy, tibia tubercle transfer and ACL reconstruction.  He did well until December 2003 after beginning mandatory physical training and running.  X-rays of the knees showed mild degenerative changes.  

The 19 July 2004 MEB NARSUM examination, 7 months prior to separation, noted complaints of bilateral anterior knee pain.  Physical examination showed “pain/tenderness to both anterior knees,” but both knees were ligamentous stable.  At the 1 September 2004 orthopedic follow-up examination for the right knee, the examiner recorded ROM of 0-125 (normal 0-140).  The 10 September 2004 MRI of the right knee showed minimal degenerative spurring.  

At the 29 April 2005 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported 5-7/10 right knee pain and occasional give-way and locking of the bilateral knees.  Although he could not run, he could walk about a mile.  Physical examination showed a normal gait without assistive devices.  There was 1 cm of left calf atrophy compared to the right, and the left knee had mild ligamentous laxity, but the right did not.  The CI was able to fully squat without pain and there was no pain with manipulation of either knee.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (degenerative arthritis).  The VA dual rated the left knee condition 10%, coded 5010 (traumatic arthritis), and 10%, coded 5257 (recurrent subluxation or lateral instability), based on the C&P examination, citing 125 degrees of knee flexion without pain or significant functional limitation due to pain, weakness, fatigue, lack of endurance or incoordination; and slight lateral knee instability.  The VA also rated the right knee 10%, analogously coded 5299-5259 (removal of meniscus, symptomatic) based on the C&P examination, citing 125 degrees of knee flexion without pain or significant functional limitation due to pain, weakness, fatigue, lack of endurance or incoordination.

The panel first considered if the left and right knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the left and right knee conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendations for the unfitting left and right knee conditions at the time of separation. 

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45) for either knee.  There likewise was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for 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.  No additional functional limitation was evidenced by the examinations.  However, there was evidence of non-compensable limitation of motion and X-ray evidence of arthritis in each knee, which supports the 10% bilateral knee rating awarded by the PEB.  After due deliberation, considering all 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 bilateral knee condition.  

BOARD FINDINGS:  In the matter of the bilateral knee 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:

SAF/MRB

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04394.

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 rating modification or re-characterization 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 modification of your disability rating or characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.