RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX					           CASE:  PD-2014-02621
BRANCH OF SERVICE:  AIR FORCE	Separation Date:  20060410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Electrical Systems Apprentice) medically separated for a right knee condition.  The right knee condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued an L2 profile and referred for a Medical Evaluation Board (MEB).  “Right anterior medial knee pain, severe” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “anterior right knee pain, status post (S/P) anterior cruciate ligament (ACL) reconstruction with no residual instability” as unfitting, rated 10% citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB), which affirmed the PEB findings and rating and was medically separated.  

CI CONTENTION:  The CI requests the Board consider all conditions.  His complete submission is at Exhibit A.   

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 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:  

FPEB – Dated 20050801	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anterior Right Knee Pain, S/P ACL  Reconstruction With No Residual Instability	5099-5003	10%	Degenerative Joint Disease(DJD); Patellofemoral Pain Syndrome (PFPS), Right Knee	5024	10%	20060628	
			S/P ACL Reconstruction with Instability	5257	10%		
			Scar, Postoperative, Right Knee	7804	0%		
Other x 0 	Other x 5	
RATING:  10%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20061220 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Knee Condition.  The CI injured his right knee on 11 December 2003.  A right knee MRI performed in December 2003 showed a tear of the posterior portion of the lateral meniscus and a complete tear of the ACL ligament.  He was initially treated with immobilization, activity modification and physical therapy (PT).  The CI underwent right knee ACL reconstruction with lateral meniscal repair and medial meniscus debridement on 12 April 2004 with PT from December 2003 through July 2004.  The Orthopedist in January 2005 noted reports of persistent right knee pain, occasional swelling and popping, and buckling.  All of the knee symptoms were worse with running and standing.  The CI underwent a second right knee arthroscopy with a meniscal debridement on 1 February 2005.  The CI resumed PT treatment from April 2005 through February 2006.  The last PT evaluation in February 2006 noted no instability.  The MEB Narrative Summary (NARSUM) exam, approximately 8 months prior to separation, documented pain, popping, buckling, and diffuse tenderness of the knee including over the anterior medial and lateral knee.  The CI used a non-steroidal anti-inflammatory drug (NSAID) for pain control.  PT was discontinued because of poor results. The MEB NARSUM physical exam findings are summarized in the chart below.  The VA Compensation and Pension (C&P) exam approximately 3 months after separation documented right knee weakness, instability, give away, pain, stiffness, swelling, fatigability, and lack of endurance.  The CI reported no symptoms directly related to the scars.  The CI reported flares three times a month, lasting 30 to 40 minutes.  The pain was worsened by standing, walking, lifting and prolonged sitting.  He required a knee brace with increased activity.  The right knee X-ray showed degenerative joint disease.  The VA C&P physical exam findings are summarized in the chart below.  The range-of-motion (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.  

Right Knee ROM
(Degrees)	
MEB ~8 Mo. Pre-Sep
	
VA C&P ~3 Mo. Post-Sep
	
Flexion (140 Normal)	130	112*, 110  with repetition*	
Extension (0 Normal)	0	0*	
Comment	+grind; diffuse medial, lateral joint line tenderness; more localized anterior medial tenderness to palpation (TTP)
6 months post 2nd arthroscopy	*Painful motion; +1 swelling without effusion; mild medial, lateral instability; clicking, popping, crepitus, strength nml; repetitive motion-decreased strength, increased pain; pain with guarding, grimacing; Deluca + for pain, fatigue, weakness	
§4.71a Rating	10%	10%+10%(instability)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right knee condition 5099-5003 analogous to (arthritis, degenerative), rated 10%.  The VA coded the right knee condition 5257 (knee, other impairment of: recurrent subluxation or lateral instability), rated 10% (slight).  The Board considered coding under 5258 (cartilage, semilunar (meniscal), dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) however the VA examiner documented swelling without effusion on exam.  The Board next considered coding under 5259 (cartilage, semilunar, removal of, symptomatic) however that would offer the CI no benefit of a higher rating.  The CI had well documented evidence in the service treatment record of right knee pain with activity and painful motion on the MEB, treatment notes and C&P exams.  Application of VASRD §4.59 (painful motion) warranted a 10% rating for painful motion.  The Board considered whether the right knee instability could be reasonably justified as a separately unfitting for additional rating.  Although though the CI had an ACL reconstruction, multiple treatment notes documented the absence of residual instability and the VA examination documented mild medial and lateral instability but anterior and posterior drawer signs were negative for instability.  The Board determined that the right knee instability did not rise to the level of unfitting for dual ratings.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right 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 right 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 20140602 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02621.

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,

				XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings