RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00941
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140807
SEPARATION DATE:  20090426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (2T331/Vehicle & Vehicular Equipment Maintenance Apprentice) medically separated for right and left knee conditions.  The bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The right and left knee condition, characterized as “patellofemoral syndrome causing chronic 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 “right knee pain, patellofemoral syndrome with history of medial meniscus injury” and “left knee pain, patellofemoral syndrome” both as unfitting, rated at 0% each, referencing application of DoD guidance for application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION: The CI wrote:  “Knee instability, swelling, fluid in knee (still), sleeping issues.  Stress related issues due to military service along with sleeping issues.  Knee swells up due to fluid after short time period reoccurrence of cysts on tailbone, knee gives out.”

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 ratings for the unfitting bilateral knees are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  The contended stress related issues with sleep issues and cysts on the tailbone were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20081216	VA - (<1 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain, Patellofemoral syndrome 	5261	0%	Patellofemoral Syndrome, Right Knee 	5299-5260	10%	20090514	
Left Knee Pain, Patellofemoral Syndrome	5261	0%	Patellofemoral Syndrome, Left Knee 	5299-5260	10%	20090514	
Other x 0 (Not is Scope)	Other x 3	20090507
20090529	
Combined:  0%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20091020 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Right And Left Knee Patellofemoral Syndrome Condition.  According to the MEB narrative summary (NARSUM), the CI began experiencing persistent chronic bilateral anterior knee pain with most activities in the summer of 2007, including running, impact activities, climbing stairs and carrying heavy weights.  The pain improved with activity restrictions but returned with resumption of offending activities.  X-rays and magnetic resonance imaging did not demonstrate any significant abnormalities (CI had Osgood Schlatter’s changes of the bilateral tibial tuberosity, a developmental condition present prior to entry into military service and not related to the knee pain).  Evaluation by orthopedic surgery in June 2008 diagnosed bilateral patellofemoral syndrome.  At the time of the orthopedic examination, there was full range-of-motion (ROM) with stable ligaments and no joint line tenderness.  There was grinding of the patella with patellar tenderness consistent with the diagnosis.  A permanent profile restricting running, high impact activities and no "ruck sack" was recommended and an MEB was initiated.  At the time of the MEB NARSUM examination, the CI reported pain with running, walking, climbing stairs and squatting.  He stated that he did not feel capable of performing his primary AFS (vehicle maintenance) which included kneeling, lifting and straining of the lower extremities.  On examination there was no tenderness and normal motion without pain.  No pain or tenderness was observed with ambulation.  The prominent tibial tuberosities were noted (Osgood Schlatter disease).  The examiner noted the CI to be non-deployable.  The commander’s statement dated 4 August 2008 stated the CI had been performing his primary duties satisfactorily without any modification to duty schedule or missed work.  The commander stated the only restriction was the CI’s ability to perform physical training and that there was no mission impact.  The MEB performed on 8 October 2008, concluded the CI was fit and returned the CI to duty.  The CI appealed for an unfit determination in his memorandum on 14 October 2008, stating he was unable to run and had gained weight causing administrative problems.  He reported difficulty bending down and standing back up at work, and that his knee pain had slowed his work as a mechanic.  The PEB determined the CI to be unfit due to knee pain because of inability to deploy.  At the VA Compensation and Pension (C&P) joint examination performed on 14 May 2009, performed less than a month after separation, the CI reported chronic anterior knee pain aggravated by work with squatting but not necessarily kneeling.  There was intermittent stiffness and swelling and pain was increased by walking a mile.  There was no locking, instability, or problems (pain or stiffness) when driving or riding in a vehicle.  Standing was unrestricted.  On examination, the gait was normal without limp.  There was no swelling, tenderness, or atrophy of the quadriceps muscle (which often accompanies patellofemoral syndrome).  The patellar compression test was positive for patellofemoral syndrome.  The ligaments were stable.  The ROM was flexion of 135 degrees and extension to 0 degrees.  The examiner indicated the CI reported pain with motion.  There was no change after repetitive movement and the examiner stated that weakness, lack of endurance, and incoordination were not factors.  The examiner diagnosed bilateral patellofemoral pain syndrome.  C&P examinations on 7 May 2009 noted a normal gait and stated the CI was enrolled to begin an automotive program at the local community college.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated each knee 0% citing normal knee motion and DoD guidance.  The VA rated each knee 10% citing degenerative arthritis and symptoms of popping and locking.  There was no limitation of knee motion to support a minimum rating under codes for limitation of flexion or extension (5260, 5261).  There was no ligamentous instability or meniscus problem or for consideration under respective codes for those conditions (5257, 5258).  The Board considered the CI’s report of pain with use and functional impairment in squatting and climbing stairs that slowed his normal work pace and concluded a 10% rating for each knee was reasonably supported (§4.40, functional loss).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for each the right and left knee patellofemoral syndrome condition (5299-5261).

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.  In the matter of the right and left knee patellofemoral syndrome condition, the Board by a majority vote, recommends a disability rating of 10% for each knee coded 5299-5261 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  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 Patellofemoral Syndrome	5299-5261	10%	
Left Knee Patellofemoral Syndrome	5299-5261	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

Minority Opinion.  There was no limitation of motion, instability, dislocated meniscus, or other objective impairment to support a minimum rating for the knees.  Although the CI reported pain with motion, the gait was non-antalgic (normal without limp) indicating no pain with walking.  Therefore the minority voter concludes a 10% rating based on painful motion is not well supported.  Although the CI reported functional impairment in performance of his mechanic duties, his commander stated there was no impairment in his performance of in garrison duties and was “…doing good things for the Air Force in the vehicle maintenance area”.  The commander noted the only medical restriction was performance of the fitness test.  The Medical Evaluation Board (three physicians at the military treatment center) concluded the knee condition did not warrant referral to the PEB and returned the CI to duty; however, the CI appealed for an unfit determination.  The PEB concluded he was unfit due to inability to deploy.  Following separation, VA records indicated the CI was pursuing a similar career as a civilian.   The minority voter notes the VASRD is intended to rate the impairment in the average civil occupation (§4.1), and not impairment in military unique requirements such as the physical fitness test or deployment.  Although the CI experienced symptoms, the commander indicated there was no impairment at work and the CI was pursuing similar work after separation from military service.  The minority voter opines there was not occupational functional impairment that supported a 10% rating.  The minority voter concluded the preponderance of evidence did not support a 10% rating for each knee and recommends no change in the PEB adjudication for the right and left knee patellofemoral syndrome condition.

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-00941.

	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 PDBR recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the PDBR.  I concur with that finding and the conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.

							Sincerely,

Attachment:
Record of Proceedings

cc:
SAF/MRBR