RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD1300659
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140206
Separation Date:  20030108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Air Force Reserve TSGT/E-6 (3N0X1/Public Affairs [formerly 2A672/Aerospace Ground Equipment]) medically separated for right patellar chondromalacia with patellar tilt.  The CI enlisted into the Air Force, serving on active duty from 1988-1991, then in the Air Force Reserves from 1991-2001, and was activated from October 2001 until May 2002.  She had a history of chronic bilateral knee pain, the right much greater than the left; first injured while participating in a training program.  At that time, she was diagnosed with patellofemoral pain.  Initially, she received physical therapy (PT) and injections to her knees which relieved her left knee pain somewhat, but not her right knee pain and she subsequently underwent a right knee arthroscopy with lateral release in April 2002.  Despite continued improvement, it was determined that her condition hampered her ability to do her job and she was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The right knee condition, characterized as “right patellar chondromalacia with patellar tilt” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  In December 2002, the PEB adjudicated “right patellar chondromalacia with patellar tilt,” as unfitting, rated 10% but determined this condition existed prior to service (EPTS) and categorized it as “Category II, Conditions that can be unfitting but are not currently compensable or ratable.”  The CI appealed to the Board for Correction of Military Records (BCMR) which corrected the PEB’s finding and awarded her a 10% rating for the right knee condition in November 2004.

CI CONTENTION:  “The injury that ended my career was not fixed and continues to get worse.  I am still unable to run or stand, squat, kneel, bend, or walk for prolonged periods.  I have difficulty with stairs and hills.  The injury has severely limited what I am able to do on a daily basis and in regard to the type work I can perform.  The pain is constant, with it getting worse with activity.  I do not believe it should have ever been 10%.  I was also granted a 0% rating for hearing loss.  I appealed the 0% rating with reports from two independent civilian audiologists (Kansas and Colorado) who said moderate hearing loss with the need for bilateral hearing aids. The VA sent me to their doctor in Colorado, who said the loss was mild.  I worked on the flight line for the better part of 14 years and lost quite a bit of hearing, despite wearing hearing protection.  I worked on support equipment and supported B52, A10, Fl6, T37, T38, KC10, and KC135 aircraft.  I was constantly exposed to extremely loud noise for 8 to 12 hours per day.  I do not hear a lot of things and have extreme difficulty understanding people.  I avoid social situations because I cannot hear and am uncomfortable.  My family and coworkers get upset because they have to constantly repeat themselves or because I do not respond when spoken to.  I cannot hear tornado sirens and other day-to-day sounds.  The hearing loss directly impacts my life.  I do not believe I should have been rated at 0% when I have such difficulty hearing.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right knee condition is addressed below.  The requested hearing loss condition was not identified by the MEB or PEB, and thus is not within the DoDI 6040.44 defined purview of the Board.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the BCMR.

RATING COMPARISON:

Service AFBCMR– Dated 20021211	VA - 3 Mos. Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Patellar Chondromalacia with Patellar Tilt	5003-5299	10	Chondromalacia of the Right Knee, Postoperative Arthroscopic Surgery with Lateral Release	5099-5014	NSC (Not Service Connected)*	STR	
No Additional MEB/PEB Entries	Other x5	20030416	
Combined:  10%	Combined:  10%*	
Derived from VA Rating Decision (VARD) dated 20030715 (most proximate to date of separation [DOS])
*VARD dated 20060307 granted service connection and rated it 10% effective 20020518

ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed in the CI’s application, i.e., that the gravity of her condition and predictable consequences which merit consideration for a higher separation rating.  The Board utilizes the Department of Veterans Affairs evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation.  Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Right Patellar Chondromalacia with Patellar Tilt Condition:  The right knee injury is well documented as evidenced by the numerous records in the service treatment record.  The CI sustained an injury to the right knee while training in 2001.  She failed to report her injury because she would not have been allowed to complete the training.  The knee pain worsened and she was evaluated, treated with a waiver from running and physical activities and sent home without graduating.  The bilateral knee was normal.  She was seen for right knee pain in the family practice clinic and noted to have pain when she ran with physical findings of a positive McMurray’s sign (suggests meniscal injury).  The orthopedist noted medial and lateral tenderness and slight medial and lateral patellar tenderness.  The examiner diagnosed patellofemoral pain.  A magnetic resonance imaging showed medial collateral thickening compatible with a sprain.  The CI was seen in follow-up and the examining orthopedist ordered a knee patellofemoral brace.  The CI underwent a steroid injection due to worsening of pain and some tenderness in the right knee.  She continued to follow-up with orthopedics and based on a CT scan which showed patellar subluxation with borderline tilt.  The orthopedist recommended and the CI underwent a right knee arthroscopy with lateral release on 11 April 2002.  Thirteen days post-operatively, she reported the pain was decreasing; however swelling was noted.  She did well until June when she reported pain unchanged with knee grind and tenderness.  The commander issued a memorandum on the CI’s medical status and documented that she underwent right knee surgery and although medical records were requested from the CI, she did not comply and, he was requesting them from the orthopedist.  In July, the orthopedist noted ongoing symptoms and initiated an MEB with a 4T Profile.  The MEB narrative summary (NARSUM) exam accomplished approximately 4 months prior to separation noted that the CI had minimal pain with walking however there was increased pain with bending, squatting, kneeling and stair climbing.  The MEB NARSUM exam findings are summarized in the chart below.  The VA Compensation and Pension (C&P) exam accomplished approximately 3 months after separation indicated that the CI still continued to have pain and problems with her right knee although she reported that it was better.  The examiner noted that the CI had difficulty squatting, bending climbing stairs, going downstairs or walking up an incline caused pain and she was unable to run.  She also had occasional weakness, stiffness with squatting.  The VA C&P physical exam results are also summarized in the chart below.  There were three range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, summarized as follows:

Right Knee ROM (Degrees)	PT ~5.5 Mos. Pre-Sep	MEB ~4 Mos. Pre-Sep	VA C&P ~3.5 Mos. Post-Sep	
Flexion (140 Normal)	“FULL”	“FULL”	130	
Extension (0 Normal)	“FULL”	“FULL”	0	
Comment	No swelling; No TTP	Well-healed wounds; no effusion; slight patellofemoral grind; normal patellar mobility; no anterior or posterior varus/valgus laxity; neurovascularly intact	5 cm scar @ anterolateral knee; No swelling, heat, redness or locking; Normal gait, stance & coordination	

The Board directs attention to its rating recommendation based on the above evidence.  Initially the PEB categorized the right patellar chondromalacia with patellar tilt, EPTS without service aggravation as “Category II, Conditions that can be unfitting but are not currently compensable or ratable,” and coded the condition analogously as 5299-5003.  The VA analogously coded the right knee condition as 5099-5014 (osteomalacia) and eventually rated it 10%.  After the CI requested a correction of her military record, on 19 January 2005 the BCMR corrected the record to reflect a compensable award of 10% for the right knee condition.  Although there were non-compensable ROM measurements on all probative documents, all documented painful motion IAW VASRD §4.59.  In addition, crepitus was noted on the NARSUM.  There was no evidence of instability or meniscal injury to allow for application of any knee specific code.  Under code 5003, VASRD §4.71a specifies that satisfactory evidence of painful motion specifies a 10% rating for each major joint affected.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the BCMR’s adjudication for the right patellar chondromalacia with patellar tilt condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, provisions relied upon by the BCMR reliance on an EPTS/Category II determination for rating the right knee condition was operant in this case and the condition was adjudicated independently of that determination by the Board.  In the matter of the right patellar chondromalacia with patellar tilt condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the BCMR’s adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Patellar Chondromalacia with Patellar Tilt	5299-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130516, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

Dear XXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2013-00659.

	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.

Attachment:
Record of Proceedings