RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX		CASE: PD-2017-04575 BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE: 20080324

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Security Forces, medically separated for “chronic neck pain” and “bilateral patellofemoral joint arthropathy,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: No specific contention made. 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 - 20080207	VARD - 20081023	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5243	10%	Degenerative Disc Condition, Cervical Spine	5243	10%	20080821	
Bilateral Patellofemoral Joint Arthropathy	5099-5003	10%	Degenerative Changes, Right Knee	5010	0%	20080821	
			Degenerative Changes Left Knee	5010	0%	20080821	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 20%	
	
ANALYSIS SUMMARY:

Chronic Neck Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI had intermittent neck pain with arm numbness, tingling and weakness since approximately 2004 with no trauma reported. An MRI study on 15 November 2006 showed degenerative disc disease with protrusions in the lower cervical spine at C5-6-7 with foraminal compromise at C5-6.

The 11 September 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of constant 1/10 neck pain with stiffness and decreased range of motion (ROM). The pain increased to 6/10 with unpredictable neck movements and exposure to cold. Physical examination showed a normal gait and stance. Neck flexion was normal without tenderness. Neck extension and lateral rotation were approximately 75% of normal with tenderness at the extremes.  No goniometric measurements were found in evidence.

At the 21 August 2008 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported intermittent posterior neck pain which increased with neck movements. Physical examination showed normal cervical curve. There was no spasm and no tenderness on palpation. The cervical spine ROM measurements showed flexion of 45 degrees (normal) and combined ROM of 240 degrees (normal 340) with pain at end of extension only. There was no additional limitations to ROM after repetitive motion. X-rays showed mild to moderate degenerative disc disease at C4-5 and C5-6.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the neck condition 10%, coded 5243 (intervertebral disc syndrome). The VA also rated the neck condition 10%, coded 5243, based on the C&P examination, citing combined ROM of the cervical spine greater than 170 degrees but not greater than 335 degrees. The panel noted the VA examination proximate to separation was more detailed and reported ROM performed after repetitive motion. Therefore, the panel placed greater probative value on the VA examination. The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 170 degrees but not greater than 335 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 cervical spine condition.

Bilateral Patellofemoral Joint Arthropathy. 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 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. The evidence for the right and left knee conditions are presented together with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began in 2004 following a treatment course of chemotherapy for testicular cancer. X-rays on 27 April 2007 revealed minimal degenerative changes bilaterally. During the 5 September 2007 MEB evaluation, 6 months prior to separation, the examiner did not specify that the examination was for a particular knee or knees. However, he did note knee joint pain, but no swelling, redness, warmth, joint stiffness, locking, catching, buckling or popping

sounds. The 11 September 2007 MEB NARSUM examination, noted complaints of 4/10 knee pain with running and bent knee activities. Physical examination noted a normal gait and stance. Bilateral knees showed no deformities.  Knee ROM was reported as “normal.”

At the C&P evaluation the CI reported constant deep anterior bilateral knee pain with pain increasing immediately if he squatted, ran or did stair walking. Prolonged walking, standing or kneeling would also increase the pain levels. The CI denied any swelling or locking but did state a buckling sensation would occur in either knee on average of once a month. Physical examination showed a normal gait and station. There was no effusion, redness, swelling or tenderness of either knee. The left knee ROM was flexion of 141 degrees (normal 140) and extension of 0 degrees (normal). Right knee ROM was flexion of 140 degrees and extension of 0 degrees without observed manifestation of pain and without additional limitation after repetitive motion.

The panel concluded there was not a preponderance of evidence in the service records which overcame the presumption that the bundled knee condition was reasonably considered separately unfitting. The panel then considered its rating recommendation for the unfitting right and left knee conditions at the time of separation. As noted above, the PEB bundled the right knee condition with the left knee condition and applied a single 10% rating coded 5099-5003. The VA rated the right knee condition 0% and the left knee condition 0%, both coded 5010 (arthritis, due to trauma), based on the C&P examination, citing no objective evidence of painful or limited motion of a major joint.

There was no ratable limitation of motion under the diagnostic codes for limitation of flexion or extension (5260, 5261) for either knee. 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 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 knee. A bilateral 10% rating under the provisions of 5003 was considered and determined appropriate with X-ray evidence of bilateral degenerative changes of two major joints. No additional functional limitation was evidenced by the examinations. There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code for the bilateral knee condition. 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 neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. 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-2017-04575.
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.