RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00772
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141030
SEPARATION DATE:  20060627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Electrical Systems Craftsman) medically separated for a right knee condition.  The knee condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a temporary U2/L2 profile and referred for a Medical Evaluation Board (MEB).  The knee condition, characterized as “right knee pain,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated the right knee pain condition as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB), which concurred with the 10% rating, adding “presumed irritable bowel syndrome” as a Category II condition, one that can be unfitting but is not currently compensable or ratable.  A review by the Secretary of the Air Force Personnel Council upheld the FPEB adjudication and the CI was medically separated.

CI CONTENTION:  “I was released from the AF with a 10% rating.  However, the VA rated my disabilities at 30%.”

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 SAFPC – Dated 20060515	VA - (1 Mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5257-5259	10%	Chronic Strain Right Knee	5014-5260	10%	20060718	
Other x 1  (Not in Scope)	Other x 7 	
Rating:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20061206 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Knee Pain Condition.  After an injury in 2003, magnetic resonance imaging showed a possible tear of the right anterior cruciate ligament (ACL).  The CI underwent right knee arthroscopy in June 2003 at which time a lateral meniscal tear was repaired, but no ACL tear was present.  Follow-up right knee X-rays showed mild changes of osteoarthritis.  Ongoing pain led to a second arthroscopy in November 2004 that involved operative repair of cartilage lesions; the ACL was noted to be slightly lax (“1+ Lachman under direct vision”).  After surgery, injections and physical therapy, there was insufficient improvement in pain to allow return to full unrestricted activity.  At an orthopedic follow-up evaluation on 8 September 2005 (10 months prior to separation) the CI indicated that the knee did not feel unstable.  A physical exam maneuver (drawer test) did not indicate the presence of ACL instability.

At the narrative summary (NARSUM) evaluation on 8 December 2005 (7 months prior to separation), the CI reported taking over-the-counter anti-inflammatory medication for persistent pain.  He was unable to return to full running status due to his right knee condition.  He denied symptoms of locking but did report occasional giving way with pain.  Physical exam showed well-healed surgical scars and no swelling.  The anterior drawer test for ACL stability was 1-2+, indicating “anterior and anterolateral laxity that is slight.”  The examiner concluded that “he does not have significant anterior cruciate ligament laxity.”

A primary care clinic examiner on 7 April 2006 (3 months prior to separation) noted that examination findings were consistent with normal stability of all ligaments.  At a podiatry evaluation for a foot cyst on 2 May 2006 (2 months prior to separation), the CI reported that he had no gait abnormality and no difficulty walking.  He stated that foot pain “occurs with exercise…while running.”  Examination noted that no limping was present.

At the VA Compensation and Pension exam performed a month after separation, the CI reported constant right knee pain.  Flare-ups of pain occurred from climbing stairs, squatting, walking a mile, standing for 45 minutes, or any running.  He denied locking, but “he states there is no instability but he feels instable.”  He often used a knee brace.  The condition mildly affected his occupation and did not affect daily activities; however, it severely affected ability to participate in sports and recreation.  Examination showed an antalgic (limping) gait.  There was no ligament laxity present as evidenced by a negative Lachman’s test (for ACL instability) and negative varus-valgus stress (for medial and lateral collateral ligaments).  He could only partially squat due to pain.

The goniometric range-of-motion 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)	MEB ~5 Mos. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Flexion (140 Normal)	135	120	
Extension (0 Normal)	0	0	
Comment	+Tenderness	+Patellar grind	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  Although all exams reported non-compensable limitation of motion, the PEB’s 10% determination under a combination 5257-5259 code (knee, other impairment of; cartilage, removal of, symptomatic) was appropriate considering there was sufficient evidence of pain with use (§4.40; “functional loss”) and painful motion (§4.59).  It was noted that the PEB utilized the 5257 code to reflect the co-existence of some degree of laxity of the ligaments in the right knee.  However, the PEB did not consider if dual coding under separate 5257 and 5259 codes was warranted.  The VA decision stated that a separate rating for knee instability was not supported by the evidence in this case and also rated the condition at 10% under a combination 5014-5260 code (osteomalacia; limitation of flexion).  The Board considered support for a higher rating by dual coding for painful motion and instability.  The NARSUM reported an examination maneuver that could indicate some possible instability of the ACL, but concluded that significant laxity was not present.  The CI’s dominant complaint was pain.  Although he complained of occasional “giving way,” a symptom that could be linked to instability, this symptom is commonly due to pain (i.e. not true ligament instability).  Furthermore, no other examiner documented objective evidence of ligament instability.  Board members therefore agreed with the VA that a separate rating for instability under the 5257 code was not warranted.  There also was no evidence of dislocated semilunar cartilage to warrant rating under the 5258 code.  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 rating for the right knee pain condition, but recommends assigning only the 5259 code in order to maintain stricter adherence to the VASRD.

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 rating, but recommends VASRD code 5259.  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	
Right Knee Pain	5259	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140129, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		

SAF/MRB

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-00772.

	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 description 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.

Sincerely,

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR
DFAS-IN