RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02211
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150122
SEPARATION DATE:  20050320

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Vehicle Operator/Dispatcher) medically separated for left knee pain.  The left knee could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a permanent P4L4 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “chronic left knee pain, enchondroma removal with focal atypia,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left knee pain status post enchondroma removal with associated pain disorder” as unfitting, rated 20%, citing the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 IPEB – Dated 20050309	VA - (8.7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain Status Post Enchondroma Removal with Associated Pain Disorder	5015-5002	20%	Left Knee Patellar Chondromalacia	5262	10%	20051212	
			Residuals of tumor Removal, Left Femur	5299-5255	10%	20051212	
			Pain Disorder with Psychiatric Features (To Include Claim for Multiple Joint Pain)	9499-5025	30%	20051212	
Other x 0  (Not in Scope)	Other x 5  	
Combined:  20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 2006224 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Knee Pain.  The service treatment record (STR) indicated that the CI injured her left knee in a fall while running in early 2000.  Initial conservative treatments did not control her painful symptoms.  A complete radiologic work-up eventually revealed a non-malignant boney mass of the distal left femur causing mild expansion of bone.  On 21 October 2002, she underwent surgical excision of the mass with application of a bone graph and metal plating.  Post-operatively, she continued aggressive physical therapy (PT) and within 8 months, her orthopedic examination noted left knee joint-line tenderness with a normal gait and full range-of-motion (ROM).  She eventually was medically approved for flight status as a flight attendant in September 2003.  In November 2003, she again complained of left knee pain and requested another referral to PT.  Upon re-evaluation, it was decided that the retained metal plating may be the source of her returned symptoms and therefore all bone plating material was surgically removed on 23 June 2004; 9 months prior to separation.  Multiple orthopedic and PT follow-up encounters revealed full ROM to the left knee with associated joint-line tenderness and normal gait.  The final STR clinical encounter (prior to the narrative summary [NARSUM]) was conducted by orthopedics on 30 December 2004 and revealed tenderness about the left knee joint as well as the left quadriceps muscle.  Her knee ROM was “full extension” and flexion to 130 degrees (normal = 140).  At the NARSUM examination on 21 January 2005; 2 months prior to separation the CI’s chief complaint presented to the MEB was “chronic left knee and hip pain.”  The physical examination (PE) was brief noting “unremarkable for limitations” with reference to the “history of present illness (HPI)” for any objective findings.  Her diagnosis was chronic left knee pain status-post surgical description.  The commander’s statement noted that the CI’s limitations did prevent her from performing the wide-range of her required AFS duties.  

At the VA Compensation and Pension examination on 18 December 2005; performed 9 months after separation, the CI reported left knee “stiffness and pain aggravated by cold and also by standing and walking.”  The PE revealed minimal tenderness about the left kneecap with normal ROM.  There was no painful motion or instability present.  The examiner indicated that the left knee condition was “most likely patellar chondromalacia” (softening of kneecap cartilage).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the dual code 5015-5002 (new growths of benign bone-rheumatoid arthritis) citing post-surgical pain condition; whereas, the VA assigned a 10% rating under code 5262 (tibia and fibula impairment) and an additional 10% for surgical residuals IRT the distal femur, citing slight knee and hip disability, respectively.  At first glance, Board members could easily concede exam probative value was nearly exclusive to the NARSUM at 2 months prior to separation versus the VA exam at 9 months after separation.  However, the NARSUM PE did not offer much in clinical evidence as per its “exam” reference to the “history of present illness” as previously mentioned.  Board members then considered and agreed that the STR orthopedic exam just prior to the NARSUM had nearly exclusive probative value in this case and accordingly, joint and muscle tenderness were the only adverse clinical findings.

Members then deliberated on the level of impairment in light of knee ROM values being consistent and VASRD non-compensable.  Members acknowledged and agreed that the pathology presented in this case did not support a rheumatoid arthritis condition as noted in the PEB’s coding scheme, and that the 5015 code was indeed a more accurate description of the CI’s initial condition of a boney tumor growth.  Additionally, the tumor in this case was in the distal femur (directly adjacent to the knee) which is supported under code 5255 (femur impairment) at a level no greater than “marked” at 20%.  Absent knee instability, fracture pathology, surgical mal-union, or worsening evidence of limited ROM, the Board agreed that there were no available alternative joint or analogous coding options which were applicable and or advantageous to the CI’s current 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board does not recommend a change in the PEB’s adjudication for the left knee condition.

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 left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140515, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
XXXXXXXXXXXXXXXXXXXX
President
DoD 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 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-02211.

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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings