RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00786
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20070608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Information Management, medically separated for “chronic left knee pain” with a disability rating of 10%.  

CI CONTENTION:  The applicant requests we consider all conditions.  The applicants 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 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 PEB - 20070330	VARD - 20080116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Mild Degenerative Joint Disease (DJD) of the Left Knee	5010-5260	10%	20070920	
Right Knee Pain	Category II	Mild DJD of the Right Knee	5010-5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to the narrative summary (NARSUM), the CI’s knee pain increased with running in January 2006.  Radiographic studies in 2 February 2006 showed normal left knee with no significant osseous, articular or soft tissue abnormality with later radiographic in 21 February 2006 unable to exclude a tear of the medical meniscus, noting metallic artifact in the soft tissue anterior and medial to the patella.  Diagnostic arthroscopy performed on 18 July 2006 found no intra-articular pathology (normal meniscus, etc.).  

Despite treatment including physical (PT), the CI’s left knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a Medical Evaluation Board (MEB).  

At the time of orthopedic consultation examination on 13 November 2006 (7 months prior to separation) the CI reported no improvement with her left anterior knee pain.  The CI described increased pain with stairs and activities.  She denied swelling, instability but, noted presence of occasional popping.  On examination, knee motion was abnormal as summarized in the chart below.  There was no swelling, no erythema, no crepitus, no pain elicited with motion, no anterior drawer present, and no instability.  Gait was normal.  

At the MEB NARSUM examination on 8 December 2006 (6 months prior to separation) the CI reported increased pain when running, standing, kneeling, climbing stairs and arising from a chair.  The CI noted mild painful popping anteriorly, but denied swelling or locking.  The MEB physical examination noted significant hyperextension laxity of both knees which the CI reported were congenital.  No effusion, crepitus, erythema or warmth of the left knee was noted.  Examination showed the left knee was stable to varus and valgus stress with anterior drawer, posterior drawer, and Lachman reported as negative.  Patellofemoral grind was present.  Pivot shift was negative with no tenderness noted.  Gait and stance were normal.  

At the VA Compensation and Pension (C&P) examination on 20 September 2007 (4 months after separation), the CI reported she was running around the track and her knees gave out.  The CI reported “giving way,” pain, and stiffness.  The VA examination noted an antalgic gait with poor propulsion.  Reflex, sensory and motor exams were normal.  There was no instability and Lachman’s (laxity) and McMurry’s (meniscal) tests were negative.  The left knee was tender to palpation with crepitation, clicks and snaps.  There was no grinding.  Radiograph showed mild narrowing of the medial compartment joint spaces and the examiner diagnosed mild degenerative joint disease of the left knee.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned 10% rating under 5099-5003 (analogous to arthritis), citing ROM limits with patellofemoral grind.  The VA assigned a 10% rating under 5010-5260 (mild degenerative disease of the knee, due to trauma) citing painful motion.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of patellar grind (or crepitus) with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability (5257), frequent locking with effusions or any indication of dislocated meniscus or loose body (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  

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.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right knee was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The right knee was not implicated in the commander’s statement and was not judged to fail retention standards, as it was not on the MEB form (AF IMT 618).  The non-specific profile for the left knee may have overshadowed any contribution from the right knee.  The right knee was reviewed and considered by the Board.  The right knee pain was not a clinical or treatment diagnosis until 7 March 2007 (after the date of the MEB) when the CI complained of right knee pain for 2 days, with no episode of trauma.  The treatment note indicated full right knee ROM and no instability.  There was no performance based evidence from the record that the right knee condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended right knee condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  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 right knee condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope or review of 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 20140214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

Dear XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00786.

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