RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00601
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141118
SEPARATION DATE:  20080815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (3E351/Structural Journeyman) 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).  He was issued a permanent L4 profile and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “osteochondritis dissecans” (loose cartilage) was forwarded as the sole condition to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “chronic knee pain due to osteochondritis dissecans status post abrasion chondroplasty and microfracture surgery” as unfitting, rated at 10%, referencing the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 left knee condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  In addition, the CI was notified by the Army that his case is eligible for review of any mental health (MH) condition, in accordance with the Secretary of Defense directive for a comprehensive review of cases referred to a disability evaluation process between 11 September 2001 and 30 April 2012 in which MH diagnoses were changed or eliminated.  Since the CI responded to this mailing, it is presumed that he elected review of his MH condition; which was diagnosed and treated in service, although not PEB adjudicated.  Accordingly, the case file was reviewed regarding unfavorable diagnosis change, fitness determination, and rating if indicated of that condition.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20080617	VA (5 Mo. Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Knee Pain ...	5009-5003	10%	Residuals, Left Knee ...	5010	10%	20090122	
Other x 0  (Not in Scope)	Other x 4 	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20090223 (most proximate to date of separation)

ANALYSIS SUMMARY:

Left Knee Condition.  The NARSUM, corroborated by the service treatment record (STR), records a complaint of left knee pain (without discrete injury) dating to 2005.  Imaging revealed infra-patellar plica (congenital band below the knee cap); and, in November 2006, the CI underwent arthroscopic excision of the offending plica; but, a subsequent trial of physical therapy (PT) and conservative measures was unsuccessful at restoring full AFS functioning.  Range-of-motion (ROM) measurements performed by PT in January 2008 (8 months prior to separation) were flexion to 123 degrees (normal 140 degrees; minimum compensable 45 degrees) and extension 8 degrees (normal 0 degrees).  An orthopedic examination a month later documented flexion of 130 degrees, and a comprehensive PT examination of April 2008 (5 months prior to separation) documented “full” flexion with pain on flexion and extension.  Both the orthopedic and PT examiners (just referenced) documented the absence of effusion, locking, instability, or physical signs of cartilage impingement.  Earlier STR entries noted an antalgic gait, but later entries confirmed a normal gait.  There are no STR entries documenting significant ROM impairment, instability, signs of cartilage impingement, locking, persistent effusions, or other ratable findings.  

The NARSUM states “continues to have pain particularly when running, walking up a flight of stairs, and walking for significant distances”; and, provided the diagnosis of osteochondritis dissecans, although this diagnosis is not elaborated in the STR (no confirmatory imaging, etc.).  It referred to PT and orthopedic exams (presumably those cited above) for physical findings.  A VA Compensation and Pension (C&P) evaluation was performed in January 2009 (5 months after separation), and notes “chronic left knee pain for the past two years ... [with] ... flare-ups ... with ambulatory activities.”  The VA physical exam noted a normal gait, the absence of tenderness, and the absence of ligamentous laxity.  The VA ROM measurements were flexion to 115 degrees and extension 0 degrees, confirming the presence of painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA 10% ratings were under analogous 5003 (degenerative arthritis) criteria (VA code 2010 [5010] defaults to 5003).  The VA decision specifically cited painful motion (VASRD §4.59) as the basis of the minimum 10% rating, and the latter is well supported by PEB and VA evidence.  The MEB PT finding of 8 degrees extension satisfies the 10% criterion under code 5261; but, hyperextension was not corroborated by any other examiner (or clinically logical).  There is no evidence for ROM impairment, frequent effusions, or locking which would support a rating higher than 10% under any applicable code; and, no grounds for additional rating of instability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that there was insufficient cause to recommend a change in the PEB adjudication of the left knee condition.

Contended MH Condition.  The earliest entry in the available STR addressing MH concerns is a 2005 entry for depression associated with marital issues, which did not result in treatment or follow-up.  The next entry is from the psychiatric clinic in March 2007, which states “no prior history of mental illness or psychiatric treatment,” although it is noted that an S3 profile had been issued 2 months earlier.  There are three more treatment notes from the psychiatric clinic over the ensuing months (last one December 2007, 8 months prior to separation).  The CI’s depression and anxiety symptoms improved with a trial of medication adjustments (various anti-depressants); although, the acuity was still subject to fluctuation with various stressors (medical issues, pain, career threat, significant marital issues).  The Axis I diagnosis remained adjustment disorder with a depression component (variable diagnostic nomenclature for the latter).  There is no STR evidence of psychotic or other acute psychiatric symptoms; disciplinary, workplace or legal issues; alcohol/substance abuse; suicidal ideation or attempts; or psychiatric crisis/hospitalization.

The NARSUM documented a past history of “depression” without elaboration, and anti-depressants were on the medication list.  There were temporary S3/4 profiles during the period of psychiatric treatment discussed above, but a permanent S2 profile was issued in June 2007 (14 months prior to separation).  The commander’s statement did not reference any MH diagnosis or symptoms, and listed only physical limitations to performance.  A VA psychiatric C&P evaluation was conducted in January 2009 (5 months after separation), and noted that the CI was not engaged in MH treatment and “not taking any psychotropic medication at this time.”  He was fully employed as an electrician without documentation of any adverse occupational consequences of the MH condition.  The VA diagnosis was “adjustment disorder with mixed emotional features” and was rated 30%.

The Board directed attention to its recommendation based on the above evidence.  The MEB decision not to refer the adjustment disorder for PEB adjudication was grounded in an assessment that the condition met retention standards, which was supported by the permanent profile reduction to S2.  Therefore, under guidelines of the MH Review Project, there is /is no evidence that the MH diagnosis was unfavorably changed or eliminated; and, this case does/does not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Service (and VA) diagnosis of adjustment disorder is not subject to compensation IAW DoDI 1332.38 (E5.1.3.9.4) regardless of fitness implications, and members agreed that there is not a preponderance of evidence to support a recommendation to change the MH diagnosis.  Furthermore, there is no performance based evidence of significant psychiatric impairment at separation; a conclusion further supported by the lack of implication of any MH-based limitations by the commander and the permanent S2 profile.  Members thus agreed that, even conceding a ratable MH diagnosis in this case, the evidence would not support a recommendation that it was unfitting; thus, it would still not be subject to rating.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause for recommending any MH condition for an additional disability rating.

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.  In the matter of the contended MH condition (adjustment disorder), the Board unanimously agrees that it cannot recommend any psychiatric condition (alternate diagnosis) for an additional disability rating.  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 20140124, 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 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-00601.

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