RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						CASE:  PD-2014-00242
BRANCH OF SERVICE:  Air force	SEPARATION DATE:  20061030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Missile and Space Facilities Maintenance) medically separated for a left knee condition.  The condition 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 MEB forwarded “chronic knee pain” to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic knee pain, status post arthroscopy” as unfitting, rated 10% citing DoD and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI submitted a letter contending that his scoliosis and degenerative disc disease of the spine should have been included in his disability rating. 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:  

IPEB – Dated 20060912	VA* - (~14 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Knee Pain, S/P Arthroscopy	5099-5003	10%	Patellofemoral Syndrome, Status Post Partial Lateral Meniscus Resection for Discoid Meniscus, Left Knee	5014-5262	0%	20080107	
Other x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20080320 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Knee Condition.  The service treatment record (STR) documents that the CI began complaining of left knee pain in 2005.  At a family medicine encounter the CI complained of 2 weeks of left knee pain, without an inciting injury, possibly triggered by running.  The assessment listed left knee patellofemoral pain and the CI was started on a nonsteroidal anti-inflammatory drug (NSAID) and physical therapy (PT).  A left knee MRI showed a lateral discoid (atypical disc versus normal crescent shaped) meniscus (crescent-shaped fibrocartilaginous knee structure) with no internal derangement of the knee.  A PT encounter recorded persistent 6-7/10 left knee pain following 2 months of therapy.  Pain was greatest with stairs, side movements, and running.  The physical exam revealed full range-of-motion (ROM) with decreased leg press strength on the left (190 lbs.) compared to the right (270 lbs.).  The therapist reported that PT had provided no relief and the CI had exhausted all PT possibilities.  At an orthopedic surgery consultation the CI complained of 3-4 months of chronic, anterolateral, left knee pain.  Pain was exacerbated by activity and was associated with swelling, clicking, and popping.  The impression listed questionable symptomatic left knee discoid meniscus.  At the orthopedic surgery follow-up the CI complained of 6-8 months of anterolateral left knee pain.  Pain was exacerbated by activity and he denied symptom relief with interventions to date.  The impression listed symptomatic left knee discoid meniscus with the CI electing to proceed with surgery.  The CI underwent diagnostic arthroscopy and intra-operatively the meniscus had a partial discoid appearance with no evidence of degenerative tears.  A partial excision (saucerization) of the lateral meniscus was performed.  At the postoperative evaluation the orthopedic surgeon expressed uncertainty as to the cause of pain, as there was no large meniscus tear.  The surgeon stated “… certainly a partial saucerization of his discoid meniscus should help his symptoms.”  At the five month postoperative evaluation the CI complained of persistent anterior pain, with resolution of lateral knee pain.  Anterior knee pain had gotten fairly severe and he was not able to run or perform intense physical activity.  The left knee exam revealed a trace effusion and tenderness over the parapatellar facet area.  At follow-up the CI noted some improvement with his new patellofemoral brace, but complained of continued anterior knee pain.  The physical exam revealed medial joint line tenderness but no parapatellar tenderness.  The examiner opined that his labs, with only an isolated positive finding, were not suggestive of an inflammatory arthropathy (joint disease).  The impression listed patellofemoral syndrome ([PFS] symptom complex of anterior knee pain involving the patella).  The orthopedic surgeon stated “I do not really have anything else to offer…at this point other than continued strengthening and continued brace treatment.”  The narrative summary (NARSUM), 5 months before separation, recounted the history and interventions to date.  The NARSUM noted that recovery from surgery had been slow and unexpectedly painful.  It documented “The patient currently is pain free without any challenge to his knee.”  The physical exam noted the CI wore a brace recommended by orthopedic surgery.  The left knee exam revealed tenderness at the medial patella border.  There was no ligamentous laxity and the Lachman test (assesses anterior cruciate ligament) was negative.  There was “some pain” noted with the McMurray test (assesses menisci) and ROM.  Strength (5/5) and deep tendon reflexes (2+) were normal bilaterally.  The diagnosis listed PFS after his meniscectomy (partial/total surgical excision of a meniscus).  The examiner opined that the CI had not improved as expected after surgery and his prognosis was fair to guarded.  The plan was for the CI to be evaluated by another orthopedic surgeon.  The orthopedic surgery second opinion recounted the 2-year history of persistent left knee pain.  The pain had an insidious onset and was primarily related to running.  The CI had experienced a small benefit from the patellofemoral braces.  Arthroscopic surgery, PT, and conservative therapy had provided minimal or no relief.  The rheumatologic workup was within normal limits.  The left knee exam revealed mild patellofemoral crepitus (grating sound or sensation) and cracking with no effusion or joint line tenderness.  The patellar apprehension test (apprehension or pain on quadriceps contraction with patella displaced) was very mildly positive and the patellar grind test (assesses abnormal patellar movement and painful crepitation) was negative.  The knee was stable to straight line and rotational testing with full and unobstructed ROM.  The surgeon documented the plain X-rays, MRI, rheumatologic workup, and diagnostic arthroscopy showed no evidence of rheumatoid arthritis or osteoarthritis.  He did not believe that the meniscus was the pain source as there was no evidence of meniscal pathology on clinical exam and the arthroscopy had addressed the slight discoid lateral meniscus.  While there was some crepitus, the patella appeared to track well.  The surgeon opined the CI had a very mild amount of patellofemoral dysfunction and the assessment listed probable PFS.  The compensation and pension (C&P) exam for joint, one month after separation, recounted the history and interventions to date.  The CI complained of intermittent, anterior left knee pain with occasional popping, grinding, swelling, and fatigue.  Pain was exacerbated by stairs, squatting, kneeling, or running and relieved by straightening his knee.  He denied knee locking or giving way.  The CI reported wearing a brace to work (full time commercial heating, ventilation, and air conditioning mechanic) and denied taking medications.  The physical exam documented a normal symmetrical gait while wearing a hinged left knee brace.  The left knee exam revealed mild medial joint line tenderness, no effusion, and no grossly apparent deformity.  The valgus/varus stress (assesses medial/lateral collateral ligaments), anterior drawer (assesses anterior cruciate ligament), and McMurray tests were negative.  The patellar compression (apprehension) test was negative.  The ROM testing revealed full extension and 140 degrees of flexion, with a mild anterior ache at full flexion.  There was no change with repetitive ROM exam.  Motor strength (5/5) and reflexes (2+) were normal and sensation was diffusely intact.  A left knee X-ray showed mild medial joint space narrowing with no evidence of fracture or dislocation.  The diagnoses listed left knee PFS status post partial lateral meniscus resection for discoid meniscus.

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB, rated the left knee condition at 10% (VA code 5099-5003; rating by analogy-degenerative arthritis).  The PEB cited chronic knee pain status-post arthroscopy.  The VA rating decision (VARD), citing the C&P exam one month after separation, rated the left knee condition at 0% (5014-5262; osteomalacia-tibia and fibula, impairment of).  The VARD cited left knee pain, mild tenderness, crepitus, slight knee disability, discoid meniscus by MRI, status post partial lateral meniscus resection, mild medial joint space narrowing by X-ray, normal ROM, no change with repetitive ROM,  and normal strength, sensation, reflexes, and gait.  Patellar compression, McMurray, varus/valgus stress, and anterior drawer tests were negative.  There was no dislocation, giving way, locking, effusion, fracture, malunion, or nonunion.  The orthopedic surgery and C&P exams did not demonstrate limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  While the CI underwent a partial excision (saucerization) of the lateral meniscus, there was no dislocated meniscus (5258), or symptomatic removed meniscus (5259), to support a minimum rating under the respective codes.  There was no ankylosis (5256) or instability (5257) to support a minimum rating under the respective codes.  The Board agreed a 10% rating was supported based on functional loss (§4.40) or painful motion (§4.59).  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 for the left knee 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.  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 left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140105, 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

XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00242.

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,

								XXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings