RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-02245
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140804
SEPARATION DATE:  20070928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (3P011/Security Forces Helper-in training) medically separated for a left knee condition.  The left 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 left knee condition, characterized as “left knee pain with chondromalacia patella” by the MEB, was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “persistent left knee pain due to patella femoral syndrome” as unfitting, rated 10%, referencing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI simply stated, “Please see 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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting left knee condition is addressed below; and, no additional conditions are 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 20070814	VA - (>5 Years Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain due to Patellofemoral Syndrome	5099-5003	10%	Osteoarthritis with Chondromalacia and Recurrent Subluxation and Dislocation, Left Knee	5003-5257	30%	20130311	
Other x 0 (Not in Scope)	Other x 1	
Rating:  10%	Rating:  30%	
Derived from VA Rating Decision (VARD) dated 20130402 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

Left Knee Condition.  The narrative summary (NARSUM) noted left knee injuries in December 2006 (pain resolved) and in January 2007 where he twisted and subluxed (incomplete or partial dislocation) his knee requiring treatment in the emergency department.  Knee pain worsened despite conservative treatment of extensive rest, medication, and physical therapy.  X-rays from January 2007 documented a joint effusion above the kneecap and a small bony projection (osteophyte) at the back of the lower kneecap which was considered likely to be from an old avulsion injury (break of bone or tear of attachment).  This was read as “IMPRESSION:  Suspect old avulsion injury of the medial aspect of patella perhaps from lateral patellar dislocation.  Small suprapatellar joint effusion.”  Orthopedic evaluation in March 2007 found normal gait with slight effusion, tenderness, and no instability of the knee.  Range-of-motion (ROM) was 0-135 degrees (normal 0-140 degrees) with a tentative diagnosis of patellar tendinitis.  Magnetic resonance imaging (MRI) from April 2007 was read as “IMPRESSION:  Chronic avulsion injury of the medial aspect of the patella.  Mild patellar apex and medial facet cartilage irregularities with mild adjacent edema.  Suspect jumpers knee [an insertional tendinopathy] versus patellar tracking disorder.”  

At the MEB exam, the CI reported left knee pain with a grating sensation in the knee, a popping sound heard in the knee, and the knee joint feeling “out of place.”  The kneecap (patella) did not feel out of place and there was no sudden buckling, catching, or locking of the knee.  The CI denied swelling, clicking, or snapping of the knee and denied a feeling of knee or patella instability.  The MEB physical exam noted normal knee motion and appearance with a normal angle to the kneecap (Q angle).  There was tenderness on palpation of the patellofemoral area (upper kneecap) with no signs of laxity or instability of the knee or patella.  There was no weakness or neurologic deficit.  The examiner stated “tenderness was observed on ambulation.”  The NARSUM final diagnosis was “dislocation of knee patella left:  chronic left knee pain, secondary to subluxation.”  

At the VA Compensation and Pension exam performed over 5 years after separation, the CI reported recurrent pain and swelling of his left knee with “38 dislocations to date.”  The most recent dislocation was 18 months prior to the exam.  He had pain with swelling for 1 to 2 weeks when aggravated by cold, stairs, squatting or twisting and when exacerbated he wore a brace.  Exam documented non-painful ROM of 0-140 degrees (normal) with no swelling, tenderness or instability on testing.  The examiner stated there was evidence or history of severe recurrent patellar subluxation/dislocation, and listed the in-service imaging studies noted above.

The Board directs attention to its rating recommendation based on the above evidence.  Although the final PEB diagnosis was persistent knee pain “due to Patellofemoral Syndrome” and the MEB diagnosis was due to “chondromalacia patella,” the NARSUM diagnosis was due to “subluxation.”  Radiographs indicated degenerative changes (chondromalacia) to the knee cap and a chronic avulsion injury (a motion fracture).  Proximate to separation, the NARSUM exam documented painful motion (10% IAW VASRD §4.59) and the Board deliberated if the in-service imaging and history was consistent with some patellar instability, and, if so, if it was at the slight (10%), moderate (20%) or severe (30%) level under disability code 5257 (Knee, other impairment of:  Recurrent subluxation or lateral instability).

The VA exam and history stating severe instability was very remote from separation.  It was considered to be post-separation worsening and not indicative of the CI’s disability picture proximate to separation.  Given the NARSUM diagnosis and frequent, or chronic, swelling around the kneecap to include imaging abnormalities, the Board consensus was that recurrent patellar subluxation was as likely as not.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends disability ratings of the left knee condition of 10% for painful motion (5009-5003) and 10% (5257, slight) for patellar 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.  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, the Board majority recommends a disability rating of 10% for painful motion (5009-5003) and 10% (5257, slight) for patellar instability 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:

UNFITTING CONDITION	VASRD CODE	RATING	
Left Knee Pain due to Patellofemoral Syndrome	5099-5003	10%	
Left Knee Instability due to Patellofemoral Syndrome	5299-5257	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

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-2014-02245.

	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,

XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR