RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00930
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150312
SEPARATION DATE:  20091027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Air National Guard E-5 (Electric Power Production Journeyman) medically separated for chronic left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic left knee pain, patellofemoral syndrome, status post (s/p) arthroscopy x2” as unfitting rated 10%, citing application of the Department of Defense Instruction (DoDI) 1332.39 and the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I have continued to experience issues with my knee, which has led to major left knee surgery. My physical abilities have been severly limited.”

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:

IPEB – Dated 20090729	VA* - (~21 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain, Patellofemoral Syndrome, s/p Arthroscopy x2	5099-5003	10%	Degenerative Arthritis, Left Knee	5260-5003	10%	20110803 	
			Internal Derangement, Left Knee	5003-5257	30%	20110803	
Other x0	Other x1	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20120720 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Left Knee Pain.  The evidence documents that the CI suffered a left knee injury in November 2007 while playing flag football during her deployment to Iraq.  She experienced continued pain and swelling, and was evacuated to the regional medical center for further evaluation.  She was evaluated by orthopedics and a magnetic resonance imaging (MRI) revealed study revealed partial tears of the medial collateral ligaments (MCL) and anterior cruciate ligaments (ACL) and a bruised lateral femoral condyle.  She was sent back to her state-side base where she continued to complain of 4/10 left knee pain with stiffness, swelling and instability that interrupted her sleep.  Her symptoms were made worse by any activity, especially walking and climbing stairs.  She underwent her first arthroscopic procedure in March 2008 that revealed strong end points of Lachman’s and Anterior Drawer.  There was suggestion of a mild pivot shift, which was not reproducible, and no collateral or rotatory instability.  The meniscus was medial normal and there was laxity of the ACL on probing.  There was also a Grade II/III chondral lesion that required chondroplasty.  The CI progressed through physical therapy (PT) for her rehabilitation yet she continued to experience left knee pain but denied instability.  She was seen for a second opinion and an MRI arthrogram was requested.  That study revealed interval healing of the partial tears of the anterior ACL and MCL and the previously noted chondral lesion.  Also identified was a new partial tear of the posterior cruciate ligament (PCL).  There was irregularity of the medial and lateral meniscus which may be post-operative; however, meniscal tears could not be excluded.  The CI then underwent her second arthroscopic procedure in November 2008 that revealed the following findings: a “significant” tear of the PCL and an intact ACL.  No meniscal tears or pathology.  The intraoperative posterior drawer test revealed that she did have significant laxity posteriorly.  Again she went through post-operative rehabilitation.  She had a second opinion orthopedic examination due to continued symptoms and that exam contained the following pertinent entries:  full range-of-motion (ROM) with tenderness to palpation, positive Lachman’s test, negative posterior drawer, and positive laxity of her ACL.  The examiner concluded that her main problem was pain and not instability.  Less than a month later on 27 March 2009, she had another orthopedic evaluation by her originally treating  provider that concluded with the impression the CI had internal derangement of the knee with patellofemoral syndrome and instability, secondary to PCL insufficiency.

The narrative summary (NARSUM) prepared approximately 5 months prior to separation noted the CI had pain in the knee ranging from 1/10 to 6/10 daily, depending upon her activity.  She noted a lot of pain with going down the stairs as well as getting out of the car, where she noted that her knee would buckle at times.  Leg extension was very painful to her.  The pertinent physical exam findings are summarized in the chart below.  At the VA Compensation and Pension exam performed 21 months after separation, the CI reported no improvement in knee symptoms after both prior to separation surgical procedures in spite of 2 months of rehabilitation after surgery.  Her left knee had stiffness, worse in am, with persistent pain.  She continued to work on an exercise program and was not as limited in her activity but had significant pain with any activity.  The pertinent physical exam findings are summarized below.

The goniometric ROM 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.

Left Knee ROM (Degrees)	PT ~5.5 Mo. Pre-Sep	NARSUM ~5.5 Mo. Pre-Sep.	VA C&P ~21 Mo. Post-Sep	
Flexion (140 Normal)	140	Normal ROM	120	
Extension (0 Normal)	0		0	
Comment	Normal gait; No painful motion; Pos. evidence of instability; Pos. atrophy & weakness of quadriceps	No effusion, Posterior drawer test mushy but good end-point; Neg. Anterior drawer & McMurray's; Pos. crepitus	Pos. Deluca criteria & evidence of instability; Pos. painful motion; Normal strength	
§4.71a Rating	10% or 20%	10% (PEB 10%)	20% or 30% (VA 30%)	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB applied the analogous VASRD code of 5099-5003 (degenerative arthritis) and rated the left knee at 10%.  After review by a Decision Review Officer, the VA applied two different VASRD codes to the left knee condition; 5260 (limitation of leg flexion) with 5003 rated at 10%, and 5003-5257 (other impairment of the knee) rated at 30%.  The VA’s 30% rating was based on severe patellar subluxation which was not supported by the evidence as present prior to separation.  The Board first considered the PEB’s application of code 5099-5003 and the 10% rating.  The evidence present for review supports that the CI’s left knee ROM was non-compensable under VASRD rating criteria.  The PT and NARSUM exams did not document painful motion; however, the NARSUM and PT exams did document crepitus and quadriceps atrophy with weakness which IAW VASRD §4.45 (the joints) and §4.59 (painful motion) support the PEB’s 10% rating under 5003.  Additionally, this case justifies Board consideration of a separate rating for instability as established by formal VA policy in effect at the time of separation (General Counsel Opinion of 1 July 1997 and Fast Letter 04-22 of 1 October 2004).  By prior legal opinion and firm precedent, the Board adheres to this guidance.  The Board notes that the data does support that the CI suffered an injury to her cruciate and medial collateral ligaments which are responsible for knee stability.  Prior to separation, she experienced symptoms of instability and two separate examiners (the physical therapist and orthopedic surgeon) documented the presence of some level of instability on exam.  The rating criteria for knee instability are copied below for the reader’s convenience:

5257 Knee, other impairment of: 
Recurrent subluxation or lateral instability: 
Severe ................................................................................................ 30
Moderate ........................................................................................... 20
Slight .................................................................................................. 10

There were no documented episodes of knee dislocation or emergency treatment for an acute instability episode; therefore, Board members agreed that the CI did not have “severe” instability.  The NARSUM documented that the posterior drawer test was “mushy” but had a “good end-point” with a negative anterior drawer & McMurray's test.  The PT documented a positive anterior drawer test of the left knee and mild posterior drawer laxity when compared with the contralateral side and an intraoperative posterior drawer test revealed that she did have significant laxity posteriorly.  The Board did not identify any prior to separation episodes or complaints of knee giving out and only one complaint of buckling.  She did not require any significant knee bracing for any functional purpose, just a neoprene sleeve.  Board members agreed that the CI did not meet the criteria for the “moderate” 20% rating under code 5257.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a combined disability rating of 20% for the chronic left knee condition, recognizing ratable pain and instability.

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.  As discussed above, likely PEB reliance on DoDI 1332.39 for rating chronic left knee pain was operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the chronic left knee pain condition, the Board unanimously recommends a dual rating of 10%, coded 5099-5003 and a 10% rating coded 5257 IAW VASRD §4.71a.  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:

CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain…	

Chronic Left Knee Pain…	5099-5003	10%	
	5257	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140220, 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-2014-00930.

	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