RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE: PD-2014-02696 
BRANCH OF SERVICE:  AIR FORCE	     SEPARATION DATE:  20061115 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Airborne Warning Apprentice, medically separated for “left knee pain (patellofemoral syndrome)” rated at 10%.

CI CONTENTION:  “My Left Knee has affected my hips and back. I have been recently awarded 10% for my right hip due to my left knee bringing my VA disability up to 20%.  Left Knee 10% original + Right hip 10% due to Left Knee= 20%.”  The CI’s 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 – 20061002	VARD 20131031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
 Chronic Left Knee Pain (Patellofemoral Syndrome)	5399-5003	10%	Left Knee Strain, Status Post                   Lateral Release	5260	10%	20131007	
RATING:  10%	RATING:  10%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee arthroscopic surgery (lateral release – loosening of tissue around the knee cap) in November 2003 for a bone bruise.  The CI underwent physical therapy (PT) post-surgery after which she was somewhat improved.  She became pregnant and continued with PT.  A magnetic resonance imaging (MRI) report in June 2005 showed a repetitive injury of the inferior lateral aspect of the CI’s patella (knee cap) and adjoining patellar tendon, with slight lateral placement of the patella within the inter-epicondylar groove.  Despite profiles and ongoing treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  

At the time of the orthopedic clinic appointment on 2 May 2006, 30 months after surgery and 7 months prior to separation, the CI reported problems with hyper-flexing her left knee, which caused pain in the anterior aspect of the knee.  She had pain and grinding with stairs as well as with running.  She had not tried strengthening on a regular basis, and was not using non-steroidal anti-inflammatory (NSAIDS) medication.  The examiner recorded normal patellar alignment (normal Q angle).  Knee range of motion (ROM) measurements were as full.  The left knee showed generalized tenderness with a positive grind test.  There was no evidence of meniscal pathology or instability.  There was no knee effusion.  The examiner noted there was significant quadriceps atrophy and recommended aggressive PT for strengthening and prescribed anti-inflammatory medication.

At the MEB NARSUM examination on 17 May 2006, 31 months after surgery and 6 months prior to separation, the CI reported continued pain in her left knee with “give way” sensations which she reported caused her to fall for no reason.  She was unable to run, do fitness activities or perform significant portions of her job.  The examiner reported generalized tenderness throughout the CI’s left knee.  Tests for meniscal injury and instability were negative and no joint effusion was noted.  The scar site appeared well healed.  The CI was deemed not to be a surgical candidate.  ROM testing again was full.  An MEB NARSUM addendum on 28 August 2006, 3 months prior to separation, recorded that the CI had improved significantly on pain management medication.  Her ROM continued to be full.  The examiner’s assessment was patellofemoral pain syndrome PFPS with muscle atrophy and continued PT for strengthening was recommended.  

At the VA Compensation and Pension (C&P) examination on 7 October 2013, performed 7 years after separation, the CI reported falling in 2013 and injuring her patella, after which her pain was 7/10.  She wore a brace on her left knee and reported no therapy since her discharge from active duty.  She also reported that flare ups did not impact the function of her left knee or lower leg.  ROM measurements were recorded per the chart above.  After repetitive use, the examiner recorded functional loss due to loss of motion and pain on movement, and interference with sitting, standing and weight bearing.  Tenderness to palpation was noted.  Muscle strength was 5/5 and tests for instability were negative. No meniscal conditions were noted. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10% analogously coded 5399-5003, which appeared to the Board to be a combined code indicating analogous to degenerative arthritis (5003), with muscle weakness (5399).  Seven years after separation, the VA also rated the left knee condition 10% coded 5260, (leg, limitation of flexion), citing painful motion of the knee (VASRD §4.59).  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The Board did not consider the VA examination probative given its remoteness from the separation date.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), frequent locking with effusions or any indication of dislocated meniscus or loose body (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  

After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left knee condition.  

BOARD FINDINGS:  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.  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 20140605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02696.

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,

Attachment:
Record of Proceedings