RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00143
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150508
SEPARATION DATE:  20090426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Communication-Computer Systems Operations) medically separated for right knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was placed on a duty-limiting profile and referred for a Medical Evaluation Board (MEB).  The “bilateral knee pain” condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “right knee pain with osteoarthritis” and “left knee pain with osteoarthritis” as unfitting, rated 10% and 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB), and the Secretary of the Air Force Personnel Council (SAFPC) directed the CI be returned to active duty.  A second MEB forwarded “arthritis due to trauma,” “osteoarthritis” and “obstructive sleep apnea w/CPAP” for continued active duty; the IPEB adjudicated “knee pain due to osteoarthritis and trauma” as unfitting, rated 10%, and determined the obstructive sleep apnea (OSA) condition to be Category II (can be unfit, but not compensable or ratable), citing application of the VASRD.  The CI appealed to the FPEB, which affirmed the PEB finding and rating.  A final appeal to the SAFPC also reaffirmed the FPEB finding and rating, and the CI was medically separated.

CI CONTENTION:  “My Obstructive Sleep Apnea condition treated by CPAP device (VASRD code 6847) was found unfitting but not currently compensable or ratable in contravention to the rating policy guidance established by the National Defense Authorization Act of 2008.  This should have been considered in conjunction with the rating for my knee.  Request PDBR review all VA compensated medical conditions when separated.”  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

FPEB – Dated 20090330	VA* – ~11 Mos. Post-Separation 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain …	5003	10%	Arthritis of the Right Knee	5010	10%	20100315	
Obstructive Sleep Apnea	Cat II	Obstructive Sleep Apnea	6847	50%	20100315	
Other x 0 (Not In Scope)	Other x 16 	
RATING:  10%	COMBINED:  80%	
*Derived from VA Rating Decision (VARD) dated 20101021 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Knee Pain due to Osteoarthritis and Trauma Condition.  On 29 January 1998, the CI underwent a right knee diagnostic arthroscopy for anterior knee pain.  The arthroscopy revealed a right medial plica (a thick fibrous band that rubs against the medial femur) causing anterior knee pain; this was debrided.  There was also evidence of a healing medial meniscal tear.  The CI was symptom-free until 3 to 4 months after surgery, when he sustained a right knee twisting injury with new onset pain and swelling.  On 8 December 1998, the CI underwent a second right knee arthroscopy with findings of patella chondromalacia, marked reactive synovitis (inflammation in the knee), evidence of an old meniscal tear, and minimal lateral joint line arthritis.  There was no evidence of ligamentous or new meniscal tears.  The medical records were silent for right lower extremity pain until June 2004, when the CI presented with a 2-day history of right ankle injury and a 3-day history of shin splints.  The examiner noted a past medical history of knee surgeries and a diagnosis of Osgood Schlatter disease; however, the CI reported that his knees were “OK.”  An orthopedic referral note, dated 21 October 2005, noted that the CI’s right knee was doing well until an acute injury on 18 October 2005.  The CI was referred to physical therapy and profiled for no running or prolonged standing.  An orthopedic evaluation, dated 28 October 2009, revealed trace swelling (effusion), medial joint line tenderness on palpation, positive meniscal testing (McMurray test), and knee flexion of 0-115 degrees.  Provisional diagnoses of internal derangement of knee medial meniscus versus osteoarthritis of the right knee were rendered.  A magnetic resonance imaging study, performed on 21 November 2005, revealed no evidence of a medial meniscus tear.  On 10 October 2006, the CI underwent a third right knee arthroscopy with a partial synovectomy for chronic right knee pain.  At a rheumatology consultation, dated 7 November 2006, the CI was diagnosed with bilateral patellofemoral syndrome and the examiner opined that there was no evidence of an inflammatory component.

The narrative summary orthopedic evaluation, dated 30 July 2008, noted that surgery was not indicated.  The CI reported constant right knee swelling.  He reported bilateral knee pain (rated 8/10 on the right and 6/10 on the left) and patella popping.  The knee examination demonstrated trace effusion, tenderness to palpation at the joint line and over the patella tendon, and pain with flexion to 100 degrees.  A diagnosis of arthritis due to trauma was rendered.

At the VA Compensation and Pension examination, performed 11 months after separation, the CI reported constant, right greater than left knee pain.  He reported that he used a knee brace for pain reduction and stabilization.  The pain intensified with walking greater than a mile.  The physical examination noted surgical arthroscopic scars, no joint effusion bilaterally, “distinct” right medial knee tenderness to palpation, and slight patella displacement pain.  There was no evidence of meniscal or ligamentous pathology.  A diagnosis of arthritis in both knees was rendered.

The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Knee ROM
(Degrees)	ORTHO ~10 Mo. Pre-Sep	VA C&P ~11 Mo. Post-Sep 	
Flexion (140 Normal)	120	133	
Extension (0 Normal)	0	0	
Comment	AO	AO	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the right knee pain condition as unfitting with a disability rating of 10% using VASRD code 5003 (degenerative arthritis).  The VA also rated the condition at 10% coded 5010 (arthritis due to trauma).  The Board considered whether the evidence supported a higher than 10% rating.  There was no evidence of occasional incapacitating exacerbations (5003), moderate knee instability (5257), or leg limitation of motion to 30 degrees of flexion (5260) or 15 degrees of extension (5261) for a 20% rating.  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 PEB adjudication of the right knee pain condition. The Board concluded therefore that this condition could not be recommended for additional disability rating.

Contended PEB Conditions – Obstructive Sleep Apnea.  The Board’s main charge is to assess the fairness of the PEB’s Category II adjudication of the OSA condition requiring continuous positive airway pressure (CPAP).  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Treatment records evidenced that the CI was diagnosed with mild OSA in 2002.  At that time, he was treated with a mandibular repositioning device.  The records were silent for OSA until January 2008 when the CI presented with reports of snoring and choking in his sleep.  A sleep study, performed on 12 August 2008, demonstrated OSA and recommended CPAP use.  The CI was also diagnosed with restless leg syndrome and treated with Clonazepam.  At a follow-up evaluation, dated 16 October 2008, the CI reported that he had “the best night sleep ever” with use of the CPAP device.  In November 2008, the CI underwent a septoplasty with improved nasal airflow.  On 16 December 2008, the CI reported mixed success with the CPAP device and reported continued fatigue and bouts of sleepiness.  A treatment note, dated 21 January 2009, documented that the CI removed the CPAP mask due to feelings of claustrophobia and that the examiner recommended a lower profile mask for increased compliance.

The Board deliberated whether the preponderance of the evidence supported that the OSA condition rose to the level of unfitting.  The OSA was implicated in the commander’s statement, but was not judged to fail retention standards because the CI continued to perform his duties.  All were reviewed and considered by the Board.  There was no performance-based evidence from the record that the sleep apnea condition significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the OSA contended condition and so no additional disability ratings are recommended.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended OSA condition, the Board unanimously recommends no change from the PEB determination as Category II, not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131229, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

Dear XXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00143.

	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,

Attachment:
Record of Proceedings