RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00894
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150319
Separation Date:  20040811

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air Reserve E-6 (Aerospace Maintenance Craftsman) medically separated for bilateral osteoarthritis of the knees.  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 temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The bilateral osteoarthritis of the knees condition, characterized as “bilateral knee pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “bilateral osteoarthritis of the knees” as unfitting, rated 10% with cited application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB) which made the following changes: bilateral osteoarthritis of the knees as unfitting, rated 20% and added right shoulder pain as a Category II (“Conditions that can be unfitting but are not currently compensable or ratable”).  The CI made no further appeals and was separated.

CI CONTENTION:  “I disagree with the Formal Physical Evaluation Board's decision to not include the impingement of my right shoulder and left foot condition as unfitting.”

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:

Service FPEB – Dated 20070511	VA - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Osteoarthritis of the Knee	5003	20%	Residual of Right Knee Injury, Status Post Medial Meniscectomy with Degenerative Joint Disease	5259-5010	10%	20071108	
			Right Knee Instability	5257	10%	20071108	
Right Shoulder Pain	5202	Category II	Impingement Right Shoulder	5201	10%	20071108	
Other x0	Other x1	
Combined:  20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20080320 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

The PEB rated the bilateral knee pain the single analogous code 5099-5022 (Periostitis) code.  This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation.  The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as separately unfitting.  Since §4.71a criteria are met for separate joint ratings for the bilateral knee pain in this case, the Board is pursuing separate rating and fitness evaluations as follow.

The Board first considered if the left and right knee pain, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above.  The CI was on a permanent profile with limitations that would have resulted from either condition alone. The commander’s statement documented that due to the osteoarthritis in joints, the CI could not perform his AFS.  The MEB examiner documented that given the CI’s bilateral OA symptoms that he would not be able to participate in mandatory fitness training which would render him worldwide disqualified and non-deployable.  All members agreed that the left and right knee pain, as isolated conditions, would have each rendered the CI incapable of continued service within his training for his AFS and accordingly merits separate ratings.

Bilateral Osteoarthritis of the Knee Condition.  The CI had a long history of bilateral knee problems which started with the right knee in 1987.  He was diagnosed with a torn medial meniscus and underwent an arthroscopy in December 1987.  The physical therapist documented that the CI had right knee soreness and occasional sharp pain especially with climbing stairs.  There were physical exam findings of painful range-of-motion (ROM); strength 4/5 and pain with resisted extension; positive varus and valgus; guarding tenderness on medial and lateral patellar borders and visible muscle atrophy right greater than left with decreased quadriceps strength.  The CI was diagnosed with right knee degenerative joint disease in 1991.  The bilateral knee X-ray was normal.  The orthopedist noted right knee pain with ROM limited to 125 degrees and tenderness to palpation.  The CI underwent a left knee arthroscopy in 1994 and was diagnosed with OA.  The CI was seen in Medical Clinic for left knee pain and grinding, however the examiner noted that the CI was able to walk for three miles without difficulty at his job.  The Rheumatologist noted that the right knee pain responded to a non-steroidal anti-inflammatory drug (NSAID) but not the left knee.  There was no exam of the knees at this appointment.  The VA examiner noted that the CI had osteoarthritis in both knees and was “unable to do physical exercise in the form of running, etc….”  The addendum to the MEB narrative summary (NARSUM) exam prepared 17 months prior to separation documented that the CI had internal derangement of both knees which was complicated by arthritis.  The physical exam findings were that the joints ranged normally with a normal gait and normal neurological exam.  The examiner opined that the CI had bilateral osteoarthritis of the knees which prevented him from participating in mandatory fitness training and thus rendered him worldwide disqualified and non-deployable.  A right knee X-ray noted that there was a minimal degree of osteophyte formation but a decrease in height of the patellofemoral joint, a patellar femoral subchondrial sclerosis and a moderate degree of suprapatellar enthesophyte formation.  The bilateral knee X-ray revealed changes that were consistent with degenerative joint disease and articular cartilage degeneration.  The physical medicine and rehabilitation physician noted right knee crepitus and pain with stair climbing which was relieved with rest and a NSAID.  The VA examiner in November 2006 indicated that the CI was unable to climb stairs due to the pain with physical exam findings of full passive ROM (no comment on active ROM), no instability, and a positive apprehension/grind test indicative of chrondromalacia.  The examiner further noted that the CI was fitted with an “H” buttress knee brace and followed by occupational therapy.  The MEB NARSUM exam approximately 7 months prior to separation documented that the CI had been unable to participate in the fitness testing program for over a year due to his condition.  The MEB NARSUM physical exam findings are summarized in the chart below.  The VA Compensation and Pension (C&P) exam approximately 3 months after separation documented that the CI reported chronic right knee pain which varied in intensity with locking, instability and minor swelling.  He experienced difficulties with bending, kneeling and standing with flares as often as two to three times per week and required a knee brace as needed.  The VA C&P physical exam findings are summarized in the chart below.

There were two ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Knee ROM (Degrees)	MEB ~7.5 Mo. Pre-Sep	VA C&P ~3.5 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	“Joints range normally”	120	120	
Extension (0 Normal)		0	0	
Comment	Normal gait	Pos. painful motion; No instability; Pos. crepitus right knee; No Deluca criteria	
§4.71a Rating	10%	10%	0%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the bilateral osteoarthritis of the knee condition as 5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 20%.  The VA coded the residual of right knee injury, s/p medial meniscectomy with degenerative joint disease condition as 5259 (cartilage, semilunar, removal of) symptomatic with 5010 (Arthritis, due to trauma) substantiated by X-ray findings and rated at 10%.  The VA also coded the right knee instability condition as 5257 (Knee, other impairment of) and rated at 10%-slight.  The VA C&P exam focused only on the right knee, there was no mention of the left knee.  The Board agreed that based on the fact that the MEB NARSUM contained an examination of both knees, this exam had the higher probative value.  There was no right knee instability noted at the MEB exam.  All exams met the 10% criteria rating for both the right and left knee with application of VASRD §4.10 (Functional impairment), §4.40 (Functional loss) and §4.59 (painful motion).  After due deliberation in consideration of the totality of the evidence, the Board concluded that the right and left knee pain were each reasonably justified as unfitting.  Considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt) the Board recommends a disability rating of 10% coded 5003 IAW VASRD §4.71a for the right knee pain and 10% coded 5003 IAW VASRD §4.71a for the left knee pain.

Contended PEB Conditions.  The contended condition adjudicated as not unfitting by the PEB was right shoulder pain.  The PEB coded the right shoulder pain condition as 5202 (Humerus, other impairment of) and rated as a Category II condition (“Conditions that can be unfitting but are not currently compensable or ratable”).  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  This condition was not profiled or implicated in the commander’s statement.  The MEB NARSUM exam did not contain a right shoulder evaluation as it was not entered into the DES until the FPEB made its adjudication upon CI appeal.  This condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that any of this 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 FPEB fitness determination for the contended right shoulder pain condition; and, therefore, no disability rating can be recommended.

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 bilateral knee pain condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee pain condition coded 5003 and rated  10%, and an unfitting left knee pain condition, coded 5003 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended right shoulder pain condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	5003	10%	
Left Knee Pain	5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXXXXX:
	
Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00894.

	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 rating 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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR