RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00502
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aerospace Maintenance Craftsman, medically separated for “right knee pain, possible chondromalacia” and “syncope, undetermined etiology (night shift only)” rated 20% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contended for syncope and post-traumatic stress disorder (PTSD).  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 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 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 based upon a 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 PEB - 20060321	VARD - 20060706	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain, Possible Chondromalacia	5099-5003	20%	Right Knee Laxity 	5257	10%	20060519	
			Degenerative Changes, Right Knee 	5260	10%	20060519	
Syncope, Undetermined Etiology (Night Shift Only)	8299-8210	0%	Syncope	8199-8108	10%	20060519	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Knee Pain.   In August 1995, this CI injured his right knee while playing soccer.  He was evaluated, and was found to have a torn posterior cruciate ligament (PCL), and a surgical repair was done.  Over the years, his right knee was treated with medication, physical therapy (PT), surgery, and injections.  In all, three surgeries were done on the right knee.  However, in spite of all treatment efforts, the right knee pain persisted.  On 7 October 2005, the CI was seen by orthopedics.  He reported pain in the right knee, as well as some locking, catching, and giving out.  Range of motion (ROM) testing showed full extension, and about 120 degrees flexion.  There was joint line tenderness. The knee was stable to varus and valgus stress.  Distal neurocirculatory evaluation was intact.  X-rays showed moderate degenerative joint disease (DJD).  The examiner’s diagnostic impression was: “Right knee osteoarthritis, in a young active male.”     

Due to the chronic, persistent nature of the right knee pain, a Medical Evaluation Board (MEB) was initiated.  The MEB narrative summary (NARSUM) was dated 29 January 2006.  The CI reported right knee pain that was worse with standing or prolonged sitting.  On physical examination (PE) of the right knee, there was positive patellar apprehension, with pain out of proportion to the examination.  All tests for ligamentous laxity were negative.  Knee ROM was not recorded.  The NARSUM diagnosis for the knee was: “Chronic debilitating right knee pain.”

The CI separated on 5 May 2006.  Two weeks later, on 19 May 2006, he had a VA Compensation and Pension (C&P) examination.  He reported pain in the right knee, as well as grinding, popping, and cracking.  He walked with a limp, and was using a cane during ambulation.  With the cane, he could walk significant distances.  On PE of the right knee, the surgical scars were evident, but the joint otherwise appeared normal, without redness, swelling, or additional deformity.  There was 130 degrees of flexion, with pain at the extreme of flexion, and with slight extension crepitus.  There was also slight posterior laxity, in the 90 degree position.  The C&P examiner’s diagnosis for the right knee was: Post- surgical repair of torn PCL of the right knee, with recurrent pain and crepitus, and slight gait abnormality.  The ROM examinations in evidence which the Board weighed in arriving at its recommendation, are summarized in the chart below.  

Right Knee ROM
(Degrees)	Ortho ~7 Mo. Pre-Sep
(20051007)	VA C&P ~2 weeks Post-Sep
(20060519)	
Flexion (140 Normal)	“about 120”	130	
Extension (0 Normal)	0	0	

The Board directed attention to its rating recommendation based on the evidence.  The PEB and the VA chose different coding and rating options for the right knee condition.  The PEB used VASRD code 5099-5003 (analogous to Degenerative arthritis), and assigned a 20% disability rating.  The VA “dual rated” the right knee, using VASRD code 5257 (Knee, other impairment of) at 10%, and code 5260 (Leg, limitation of flexion) at 10%, for a combined right knee rating of 20%.

The Board determined that both of these approaches were valid ways to code and rate the right knee condition.  There was no path to a higher rating, because the record did not contain sufficient evidence of a seriously crippling bone or joint abnormality which would justify a rating higher than 20%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the unfitting right knee condition.    

Syncope, undetermined etiology.   According to the service treatment record (STR) and the MEB NARSUM, this CI has a history of “black out” spells, which began in the mid-1990s.  Many of these episodes seemed to occur while he was working the night shift.  On 31 January 2003, the CI was seen by Neurology.  His last syncopal spell was in October 2002, while coaching a youth soccer event.  The neurologist wrote: “Likely non-neurological in nature, as it is not associated with any other neuro symptoms.  Examination normal, MRI [magnetic resonance imaging] of brain is normal.  Patient instructed not to drive until he has a 6 month interval free of episodes.  Recommend tilt table testing, likely vasovagal in nature.”  On 14 March 2003, tilt table testing was negative.  It did not show any evidence of a neuro-cardiogenic mechanism for the syncopal spells.  However, 15% of people with neuro-cardiogenic syncope can manifest negative tilt table testing.

On or about 1 September 2005, the CI had a near-syncopal episode, while working on night shift.  He was sitting at his desk, and he experienced sweating, lightheadedness, and unsteadiness.  There was no actual loss of consciousness (LOC).  The episode dissipated after about 15 minutes. On 12 October 2005, he was again seen by Neurology.  He reported six episodes over the previous 4-5 years, mostly related to night shift.  The neurologist wrote: “I suspect this may represent a sleep disorder.  This may represent specifically a circadian rhythm disorder.  Cannot rule out atypical narcolepsy, atypical seizures, or even panic attacks.”  On 28 December 2005, a sleep study was normal.

At the May 2006 C&P examination he reported that there had been no syncopal spells since September 2005.  The Board directed attention to its rating recommendation based on the evidence.  The PEB and the VA chose different coding and rating options for the syncope condition.  The PEB used VASRD code 8299-8210 (analogous to paralysis of the vagal nerve), and assigned a 0% disability rating.  The VA chose VASRD code 8199-8108 (analogous to narcolepsy) and rated it 10%.

The Board carefully examined all of the coding and rating options that could be applied to the syncope condition, and determined that a 0% rating was appropriate in this case.  There was no path to a higher rating, because the record did not show sufficient evidence of a seriously disabling disorder which would justify a rating higher than 0%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the syncope condition.  

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the syncope condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140115, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00502.

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