RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01169
BRANCH OF SERVICE:   AIR FORCE  	SEPARATION DATE:  20080925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Surgical Service Apprentice, medically separated for right knee pain; with a disability rating of 20%.  

CI CONTENTION:  The CI makes no specific contentions in his application.  His 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 - 20080728	VARD - 20090508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5257	20%	Post-Operative Injury, Right Knee	5299-5258	20%	20090323	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  An early note in the service treatment record dated 6 December 2005 indicated the CI, who had a history of a torn meniscus of the right knee in 2002, fell one day earlier while playing basketball.  The diagnosis of a lateral collateral ligament strain was made and treatment consisted of naproxen (a nonsteroidal anti-inflammatory drug (NSAID)), neoprene sleeve, and a physical therapy consultation.  A right knee X-ray series dated 27 January 2006 demonstrated mild to moderate tricompartmental osteoarthritis with the lateral compartment most severely affected.  An MRI dated 30 January 2006 showed absence of the posterior horn and body of the lateral meniscus, full and partial thickness articulating cartilage defects of the lateral femoral condyle, and normal cruciate and collateral ligaments.  On 1 February 2006, the CI underwent right knee arthroscopy with a partial lateral meniscectomy to debride a new tear/flap and debridement and microfracture of the femur.  In May 2006, the CI underwent arthroscopy of the right knee with microfracture of a lesion of the femoral condyle, a lateral meniscal allograft transplant, and a Genzyme biopsy for a possible future autologous chrondrocyte (a cartilage cell) implantation (ACI).  By September 2006 an orthopedic surgeon indicated the results were suboptimal of the surgical procedures and opined the CI would unlikely to have a complete cure of his knee pain with nearly any treatment.  Magnetic resonance imaging (MRI) in October 2006 was essentially unchanged from the prior MRI in January 2006, although there was some new edema in the distal femur and a small knee joint effusion.  X-rays of the right knee in November 2006 were normal.  The CI underwent a partial resection of a failed posterior half of the transplant and a synovectomy (removal of the membrane surrounding the knee) of the knee with removal of a loose body on 12 September 2007.  Arthroscopy and global debridement of the trochlea (a groove on the top of the femur) and lateral compartment of the knee were performed on 28 November 2007.  Postoperative physical therapy was carried out from January 2008 through April 2008.  

The MEB narrative summary (NARSUM) dated 4 April 2007 indicated the CI had at least a year of profiles for the right knee, which had severe degenerative changes in the lateral compartment with meniscal and articular involvement.  Examination revealed 5-120 degrees of motion with significant pain with flexion.  No instability was noted, but lateral joint line pain was unequivocal.  The orthopedic surgeon mentioned the CI was slated to have reconstructive surgery within 2 months involving the lateral femoral condyle and meniscus transfer.  The MEB narrative summary (NARSUM) addendum dated 16 January 2008 noted the CI was status post multiple surgeries to the right knee and he experienced pain, which was sometimes treated with narcotics, with a severity of 8-10/10 on a daily basis that severely limited all activities and he was reduced to using a cane at all times.  Physical examination revealed a lack of 10 degrees of extension and 90 degrees flexion with moderate tenderness at the lateral joint line and some tenderness around the patella (kneecap) and patellar tendon.  There was a moderate effusion and some mild varus laxity.  The posterior cruciate ligament was intact and there was no rotary instability.  The orthopedic surgeon opined that a knee replacement was probable in the future and thought it reasonable for the CI to proceed to knee arthroplasty since his level of function was actually quite poor with regard to both activities of daily living as well as vocational activity and recreational activity.  A NARSUM addendum dated 2 April 2008 indicated the CI’s condition had not changed since January 2008.   

A duty limiting condition report dated 21 April 2008 had restrictions of no high impact activities for the right knee, no standing greater than 30 minutes, and no lifter greater than 10 pounds.  The commander’s statement, prepared by a medical officer, dated 21 April 2008 indicated that the CI’s condition prevented him from performing primary garrison military duties; his duty schedule had been modified due to his medical condition of knee instability; he would be unable to function as an operating room technician; and he could not be deployed.    

Approximately 4 months post-separation in January 2009, X-rays of the right knee showed a relatively well maintained joint space and no osteophyte formation without malalignment of the knee.  Examination on 9 February 2009 revealed a mild effusion on the right knee with tenderness over the lateral joint line and minimal tenderness on the medial joint line with no instability. 
 
At the VA Compensation and Pension (C&P) examination dated 23 March 2009, performed 6 months after separation, the CI reported that while in service for the right knee condition he had three microfracture surgeries, three arthroscopic cleanouts, one meniscal transplant(failed) and revision, and a Genzyme biopsy.  The CI indicated he could not stand, walk, climb, or squat with the right knee.  On examination he walked with the right knee stiffened.  Range-of-motion (ROM) measurements were 0 degrees extension and 120 degrees flexion with pain on motion that worsened over the last 30 degrees of flexion.  The knee was stable.  Repetitive use increased the knee pain and flare-ups occurred with heavy use of the right knee.  The diagnosis was postoperative injury of the right knee with cartilage and chondral damage.  An MRI of the right knee reported on 13 May 2009 demonstrated a deformity of the central tibial plateau and irregularity of the lateral tibial spine with marked attenuation of the lateral meniscus along with a joint effusion.  The cruciate and collateral ligaments were intact.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5257 (moderate knee impairment-recurrent subluxation or lateral instability) for the Category I (unfitting conditions which are compensable and ratable) chronic right knee pain status post multiple arthroscopic procedures.  The VA assigned a 20% rating using code 5258 (Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint.  The Board had a deliberated the CI’s rating by the Air Force FPEB with the use of code 5257 for knee impairment.  While some examinations clearly demonstrated postoperative mild instability, the Board did not have the documentation and testimony of the FPEB to consider; however, the record did address instability in the commander’s statement as well as poor function in the activities of daily living and the recommendation for a knee replacement, which the Board members felt gave justification to the PEB rating.  Nevertheless, Board members, cognizant of a VA Counsel General opinion dated 1 July 1997, which permits dual rating of the knee for instability (5257) to be combined with arthritis (5003) and is not considered pyramiding IAW VASRD §4.14.The Board then discussed the CI’s painful knee motion with a noncompensable ROM.  Therefore, an additional rating of 10% using code 5099-5003 was considered not only reasonable, but appropriate.  Additionally, Board members noted that extension was limited, which would afford another route to a higher rating using code 5261; however, at the post-separation VA examination, extension was normal, which militated against its use.  A higher rating is not warranted in the absence of severe recurrent subluxation or lateral instability, flexion limited to 15 degrees, extension limited to 20 degrees, impairment of the tibia and fibula, or ankylosis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a combined disability rating of 30% for the chronic right knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic right knee instability condition, the Board unanimously recommends a disability rating of 20%, coded 5257 IAW VASRD §4.71a. In the matter of the chronic right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a for a combined disability rating of 30%.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Right Knee Instability Condition  	5257	20%	
Chronic Right Knee Pain Condition	5099-5003	10%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
SAF/MRB

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01169.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN