RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05038
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20060313

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Mental Health Services Journeyman, medically separated for “bilateral patellofemoral syndrome” with a 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 - 20051207	VARD - 20061106	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome (PFS)	5099-5003	10%	Right Knee PFS	5259	10%	20060911	
			Left Knee PFS	5259	10%	20060911	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Syndrome.  The PEB combined the left and right patellofemoral syndrome conditions under a single rating.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and that 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 is 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 November 2003 during basic training when she experienced pain while running or marching in combat boots.  The CI underwent right release with patellar realignment on 23 July 2004; the left side was performed on 8 October 2004.  

During the 21 August 2005 MEB NARSUM, 7 months prior to separation, the CI complained of bilateral knee pain with locking of the right knee.  Physical examination showed no bilateral tenderness or effusion and strength was 5/5.  Provocative testing for instability or meniscal pathology was negative.  Bilateral range of motion (ROM) was full; painful motion was not addressed.  

At the 7 November 2005 orthopedic examination, 4 months before separation, the CI had a normal heel to toe gait, no bilateral quad or hamstring atrophy and meniscal testing was negative.  Bilateral ROM was 0-135 degrees (normal 0-140); bilateral patella crepitus occurred throughout ROM.  The right patella had a mildly positive patella apprehension test.  

The 11 September 2006 VA Compensation and Pension (C&P) evaluation, 6 months after separation, noted complaints of constant bilateral knee discomfort with locking, instability, swelling and give-way.  Physical examination showed a normal gait and ligamentously stable knees.  There was a mild bilateral knee effusion and tenderness to palpation of both knees.  Bilateral knee ROM was 0-130, but painful motion was not addressed.  There was no decrease in ROM nor increase in knee pain with repetitive motion.  

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 implicated both knees and the physical profile did not specify a specific medical condition.  Postoperative STR evidence did not provide any information that 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 left and right knee conditions 10% each, coded 5259 (cartilage, semilunar [meniscus], removal of, symptomatic), based on the C&P examination 6 months after separation, citing meniscus removal, symptomatic.  

There was no knee limitation of motion that supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, the panel majority concluded that there was evidence of painful motion with functional loss supporting a 10% rating for only the right knee (based on §4.59, §4.40 and §4.45), as reported by the orthopedic examination most proximate to separation.  Although the CI underwent surgery for both knees, neither procedure was for removal of the meniscus and so code 5259 (cartilage, semilunar, removal of, symptomatic) was not applicable in this case.  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).  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority 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 majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 20% (10% for each knee), but did not elect to submit a minority opinion.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  There are no other conditions within the panel’s scope of review for consideration.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170525, 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-2017-05038.

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