RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04625
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20051230

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

CI CONTENTION:  The unfitting knee conditions continue to worsen and negatively affect daily activities.  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 - 20051026	VARD - 20060715	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome	5099-5003	10%	Arthritis, Right Knee	5260-5003	10%	20060321	
			Left Knee Bone Spur	5260	NSC	20060321	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 (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 of the PEB.  The evidence for the right and left knee conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

Right Knee.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent right knee surgery in July 2002 with loose body removal, partial medial meniscectomy and ACL (anterior cruciate ligament) reconstruction with hamstring autograft.  A post-surgical MRI in August 2003 revealed degenerative changes in the medial femoral condyle consistent with early osteoarthritis.  He was retained after an MEB in 2003, but his right knee continued to be symptomatic.  

The 14 July 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of persistent right knee pain, worsened with running, prolonged walking, squatting, kneeling, or rising from a chair after sitting with knees flexed.  He also reported pain with using the elliptical or riding a bicycle.  He denied instability or locking, but complained of popping and swelling.  X-rays showed evidence of osteoarthritis in all three compartments of the right knee, but the CI was not a good surgical candidate according to orthopedics.  Physical examination showed a non-antalgic gait, without right knee deformity or effusion, but with tenderness over the medial joint line and patellar tenderness.  Provocative testing to elicit ligamentous instability or meniscal pathology was negative.  Range of motion (ROM) testing of the right knee showed extension-to-flexion of 0-125 (normal 0-140).  

At the 20 March 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported weakness and 6/10 right knee pain, , pain with running, stiffness with prolonged standing, occasional locking while walking, and knee popping.  Physical examination showed right knee crepitus, but gait was normal and there were “no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement.”  Right knee ROM testing showed flexion of 140 degrees and extension of 0 degrees with pain at end range in both planes of movement.  The examiner indicated the joint function of the right knee was additionally limited by pain after repetitive use, but did not quantify the degree of limitation.  

Left Knee.  According to the STR and MEB NARSUM, the CI’s left knee pain began insidiously in 2006 without injury or trauma.  Although X-rays in March 2006 were negative, the orthopedic examiner noted slight spurring on the medial femoral condyles and patellar tilt.  During the MEB NARSUM examination, 6 months prior to separation, the CI reported that the left knee pain was “not as severe or as disabling as the right knee.”  Physical examination showed a non-antalgic gait without tenderness, deformity or effusion.  Provocative testing to elicit ligamentous instability or meniscal pathology was negative.  ROM testing of the left knee showed extension-to-flexion of 0-120 degrees.  

At the C&P examination, the CI reported a 1-year history of constant 4/10 aching left knee pain with occasional popping.  The CI denied treatment for the left knee and reported no functional impairment from the left knee condition.  Physical examination showed normal gait and “no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement.”  Left knee ROM testing showed flexion of 140 degrees and extension of 0 degrees.  The examiner stated that on the left, the joint function was “not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.”  

The commander’s statement did not implicate the left knee condition, but specifically identified the right knee condition as rendering the CI “unsuitable for deployment in any manner to any location.”  The MEB did not identify or forward a left knee condition to the PEB, but specifically forwarded “right knee chronic patellofemoral syndrome and chondromalacia confirmed surgically.”  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bundled right and left knee conditions 10%, analogously coded 5099-5003.  The VA rated the right knee condition 10%, dual coded 5260-5003 (limitation of leg flexion due to degenerative arthritis), based on the C&P examination, citing painful or limited motion of a major joint.  The VA did not rate the left knee condition, but instead found it to be not service connected, citing “the evidence show[ed] this condition to be acute and transitory with no residuals.”  

Panel members first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the right knee contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  Panel members next considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement indicated “result of his knee injury” interfering with performance, but did not specify which knee.  The STR was very scant and did not address significant limitations from the left knee outside of the NARSUM with indication of orthopedic determination of left knee spurring and orthopedic diagnosis of bilateral patellofemoral syndrome.  However, since undue speculation would be required to conclude that left knee impairment would not have unacceptably interfered with the performance of military duties in combination with the right knee, members agreed that each knee was reasonably justified as separately unfitting.  

Regarding rating the left and right knee conditions, there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) and 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.  The right knee had persistence of pain after meniscal surgery which warranted a 10% analogous rating under the 5259 code (cartilage, semilunar, removal, symptomatic).  The left knee had no history of meniscal surgery, and neither knee had history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating for under that code.  There was insufficient evidence of painful motion or functional loss of the left knee for rating IAW VASRD §4.59, and therefore the left knee warranted a rating of 0% analogous to 5003.  

Given that the right knee condition would rate no higher than 10% under any VASRD code, and the left knee would rate 0%, there was no VASRD §4.71a rating higher than the combined 10% adjudicated by the PEB under any applicable code.  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:

	

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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-2017-04625.

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.