RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04646
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20060210

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Vehicle and Vehicular Equipment Maintenance Journeyman, medically separated for “chronic bilateral knee pain” with a disability rating of 10%.

CI CONTENTION:  No specific contention was 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 - 20051208	VARD - 20070605	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Right Knee Patellofemoral Pain Syndrome	5024-5260	10%	20060821	
			Left Knee Patellofemoral Pain Syndrome	5024-5260	10%	20060821	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Bilateral Knee Pain.  The PEB combined the right and left knee conditions as a single unfitting condition.  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’s initial charge in this case was therefore directed at determining if the PEB’s approach of 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 that it alone would not have caused 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 are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR), the CI’s bilateral knee condition began in 1999 without injury or trauma.  Radiographic studies in August 2003 and June 2005 were negative and there was no surgical indication.  The 25 July 2005 orthopedic examination, 7 months prior to separation, noted complaints of bilateral knee pain with bending and kneeling.  Physical examination of the knees showed bilateral crepitus of the patella.  There was no effusion, warmth tenderness or ligamentous instability of either knee.  Pain was not elicited by motion and tenderness was not observed on ambulation.  

The 4 October 2005 MEB narrative summary, 4 months prior to separation, noted complaints of bilateral chronic anterior knee pain that was worse with bending, kneeling and prolonged running or standing.  Physical examination showed no swelling or tenderness.  Bilateral range of motion (ROM) was full, but painful motion was not addressed.  Provocative testing for instability or meniscal pathology was negative, bilaterally.  During the 14 October 2005 orthopedic evaluation, 4 months prior to separation, the CI complained of chronic bilateral knee pain.  Physical examination revealed no effusion or synovitis.  The ROM was normal, but pain was present with manipulation (passive motion), bilaterally.  Provocative testing for instability or meniscal pathology was negative.  The CI was diagnosed with osteoarthritis of the knees.  

The 21 August 2006 VA Compensation and Pension (C&P) physical examination, 6 months after separation, showed no effusion or tenderness in either knee.  Provocative tests for instability or meniscal pathology were negative.  Right knee ROM was 0-110 degrees (normal 0-140), and left knee ROM was 0-120.  Painful motion was elicited in both knees.  

The panel first considered if the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement did not implicate a knee condition; the physical profile did not specify a medical condition and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with the performance of military duties, members agreed that each knee was reasonably justified as separately unfitting.  

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 (arthritis, degenerative).  The VA rated the right and left knee conditions 10% each, coded 5024-5260 (tenosynovitis-leg, limitation of flexion), based on the C&P examination, citing painful motion.  There was no knee limitation of motion that supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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.  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).  The panel agreed there was no clear evidence in the STR of painful motion with functional loss to support a 10% rating for either knee (based on §4.59, §4.40 and §4.45), as reported by the examinations proximate to separation.  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 bilateral knee pain 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:

Exhibit A.  DD Form 294, dated 20170524, 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-2017-04646.

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.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings