RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	 CASE:  PD-2014-00178
BRANCH OF SERVICE:  AIR FORCE	 SEPARATION DATE:  20060724 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Command Post Controller, medically separated for a right knee condition which could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a permanent L4 profile and referred for a Medical Evaluation Board (MEB).  The diagnosis “persistent right medial femoral condyle osteochondral defect” was forwarded as the sole submission to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “right knee pain with persistent medial femoral condyle osteochondral defect” as unfitting, rated 10%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “The medical board did not take into consideration all of my conditions....”  A detailed statement specified that the left knee was also affected, “along with other conditions not included by the board for whatever reason,” describing a complicated surgical course and the impact of the condition(s) on his “civilian workforce capacity.” The CI asserts that, “The rating for this condition should be changed due to the severity of the condition based on the lifelong affect [sic] it carries.” 

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 Veterans Affairs Schedule for Rating Disabilities (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:  
   
Service IPEB – Dated 20060605	VA* - (4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain ...	5257	10%	DJD, Right Knee... with Instability 	5010-5257	10%	20061017	
			DJD, Right Knee... S/P Reconstruction Surgery	5010-5261	10%	20061017	
Other x 0 (Not in Scope)	Other x 5 (Not in Scope)	
Combined:  10%	Combined:  30%	
* Derived from VA Rating Decision (VARD) dated 20070413 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:    

Right Knee Condition.  The service treatment record (STR) documented an onset of right knee pain with a twisting injury in unit sports (basketball) in November 1998 (18 months after enlistment); and, related a complicated clinical course with multiple surgical interventions over the ensuing years (6) to separation.  There are multiple imaging reports (MRI) and a total of seven operative reports in evidence.  In summary, the CI was initially diagnosed with a meniscal tear and an osteochondral defect (OCD, an area of destruction of the smooth articular surface of the bone, in this case the femoral condyle).  In March of 2000 he underwent his first surgical procedure, arthroscopic debridement of the meniscal tear and OCD lesion.  This was unsuccessful and there was progression of both the meniscal and OCD pathology.  Successive surgical interventions were directed at meniscal repairs and attempts to rectify the OCD lesion with grafts, and ultimately autologous chondrocyte implantation (implantation of healthy cells); the latter being the final Service surgical intervention in July 2005 (11 months pre-separation).  There are reported histories of an anterior cruciate ligament reconstruction without a history of recurrent trauma; although, there is no operative note documenting this, and there is ample imaging and intraoperative confirmation of intact cruciate and collateral ligaments throughout the clinical course.  There are multiple STR entries documenting joint stability and negative signs of impingement (locking) on exam, and none to the contrary.  There are scant entries commenting on gait, a 2001 note describing it as “slightly antalgic” and one from 2005 (a year before separation) recording it as normal.  There are multiple entries recording formal measurements of range-of-motion (ROM).  These note flexion in the range of 110-135 degrees (normal 140, minimum compensable 45) trending toward improvement, and extension of 0 degrees (normal, minimum compensable minus 10).  There is no STR evidence for more significant ROM limitation, persistent effusions, subjective locking, or periods of incapacitation after surgical recovery.

The narrative summary (NARSUM) was conducted 20 April 2006 (2 months pre-separation) and documented ongoing knee pain prohibiting running or marching, but permitting walking and all non-impact activities.  The NARSUM physical examination (no comment regarding gait) recorded joint tenderness with a “very minimal effusion,” stability to stress in all planes (elaborating all of the standard orthopedic tests [Lachman, anterior/posterior drawer signs, pivot shift, varus and valgus stress]), and negative signs of impingement (negative MacMurray’s).  No formal ROM measurements were provided in the NARSUM, although the NARSUM orthopedist had documented flexion to 130 degrees in an earlier STR entry (corroborated by a measurement of 135 degrees from a different orthopedist 2 months later).  

A VA Compensation and Pension (C&P) examination was conducted 17 October 2006 (4 months post-separation) and documented constant pain rated 6/10 “elicited by physical activity and standing for prolonged periods of time,” also noting subjective complaints of “weakness ... stiffness ... locking ... and popping and grinding.”  The VA examiner opined, “From the [right knee] condition the functional impairment is limited mobility since the surgery and cannot sit or stand for prolonged periods of time.”  The VA physical examination recorded abnormal gait (“limping to right leg”), tenderness, “locking pain,” crepitus, “anterior and posterior cruciate ligaments stability test of the right knee is abnormal with slight instability,” normal varus/valgus stability, and normal “medial and lateral meniscus test” (no mechanical impingement, e.g., objective locking).  The VA measured ROM was flexion to 90 degrees and extension of minus 10 degrees (10% compensable).  Of note this same value for extension was charted for the comparison left knee, raising the question of an entry error or confusion on the part of the examiner for this ratable evidence (especially with no logical clinical explanation or corroboration elsewhere in evidence).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was consistent with VASRD §4.71a criteria (conceding painful motion or functional loss) for the MEB ratable findings and ROM evidence.  The VA’s dual ratings invoked the C&P statement regarding “slight instability” with testing of the anterior and posterior cruciate ligaments for a separate rating under code 5257 (recurrent subluxation or instability), in addition to the additional rating under 5261 (limitation of extension) based on C&P ROM findings.  All members agreed that the preponderance of evidence does not support the presence of instability sufficient to justify a separate rating on that basis, and furthermore that the probative value of the VA evidence for compensable limitation of extension was too weak to justify a rating premised on that finding.  There is no evidence for compensable ROM impairment, frequent effusions, or locking (with objective corroboration) which would support a rating higher than 10% under any applicable code; other than consideration of analogous rating under 5299-5262 (tibia and fibula, impairment of) which offers ratings for contiguous knee disability: 20% for “moderate” and 30% for “marked.”  Member consensus was that, in light of the complex clinical course and multiple surgical interventions leading to fairly significant functional disability in this case, that analogous application of code 5262 was supported IAW VASRD §4.7 (higher of two evaluations).  Neither code 5003 based rating nor rating under any other joint code available under VASRD §4.71a adequately captures the disability in evidence.  Given the gait disturbance (C&P) and occupational limitations (lower tolerance of physical activity and prolonged standing), member consensus was that “moderate” was a fair characterization of the knee disability in evidence, satisfying the 20% criterion under code 5262.  All members agreed, however, that “marked” disability in support of a higher rating was not reflected by the evidence.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board’s consensus recommendation is a 20% rating for the right knee condition under code 5299-5262.

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 condition, the Board by a majority vote recommends a disability rating of 20%, coded 5299-5262, IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: 

UNFITTING CONDITION	VASRD CODE	RATING	
Meniscal Injury and Osteochondral Defect with Surgical Residuals, Right Knee	5299-5262	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131231, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00178.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Attachment:
1.  Directive 
2.  Record of Proceedings

cc:
SAF/MRBR