RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02808
BRANCH OF SERVICE:  AIR FORCE 	BOARD DATE:  20150519
SEPARATION DATE:  20070625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Security Forces Apprentice) medically separated for right knee pain.  The right knee condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS) or satisfy physical fitness standards.  She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  “Right knee pain s/p ACL rupture with reconstruction and revision” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated her right knee condition as unfitting, rated 10%.  The CI appealed to the Formal PEB (FPEB), which increased the rating to 20% citing application of DoDI 1332.39 paragraph E2.A1.1.15.2.2 and the CI 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 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:  

FPEB – Dated 20070508	VA* - (~7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain…s/p ACL… 	5257	20%	Residuals of Anterior Cruciate Ligament Repair, with Osteoarthritis	5010-5260	10%	20080130	
Other x 0 (Not In Scope)	Other x 8	
RATING:  20%	COMBINED RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080321 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Knee Condition.  The narrative summary (NARSUM) and treatment records noted a right knee injury in 2003 with anterior cruciate ligament (ACL) rupture and surgical repair in January 2004.  A year after ACL reconstruction, the CI had increasing laxity and instability and required a second ACL repair (revision with graft).  Both the January 2004 and July 2005 surgeries included medial meniscus debridement.  MRI performed in August of 2006 showed ACL deficiency as well as arthritic changes in multiple compartments (patellofemoral joint and medial and lateral “femoral tibial joint”).  She had been scheduled for a third surgery which was cancelled due to permanent change of station.  At the NARSUM exam (7 months pre-separation), the CI reported right knee pain with “occasional mechanical symptoms, but denies instability.”  The NARSUM physical exam noted a trace effusion, significant medial and lateral joint line tenderness (meniscal signs), crepitus with range-of-motion (ROM) testing, and discomfort with patellofemoral grind.  There was a 2A Lachman test (instability test) with no pivot shift or lateral laxity (no varus or valgus laxity at 0 or 30 degrees).  Scars were well healed.  McMurray and Apley's tests (for meniscal cartilage tear) were negative.  ROM was described as both “full” and “0-120 degrees” (normal 0-140 degrees].  The final diagnosis was “right knee ACL deficiency status post reconstruction with severe tricompartmental chondromalacia (arthritic changes).”  

At the VA Compensation and Pension (C&P) exam performed 7 months after separation, the CI reported a similar history.  The CI reported symptom of weakness, stiffness, swelling, giving way, lack of endurance, locking and tenderness, grinding noise, and tingling.  Her knee pain was 5/10 and she took a non-steroidal anti-inflammatory medication (Advil) for relief.  On examination, she had a well healed scar with normal neurologic function.  Gait was normal and ROM was 0-100 degrees with pain and not decreased following repetition.  Testing indicated no instability and no positive meniscal signs.  

The Board directed its attention to its rating recommendation based on the above evidence.  The FPEB 20% rating was IAW DoDI 1332.39, para E2.A1.1.15.2.2 which specified a 20% “moderate instability” rating “where the Lachman's test measures an instability reading of 2+” without improvement after physical therapy.  The FPEB may also have applied DoDI 1332.39, para 6.4 (pyramiding) which historically did not allow dual rating of the knee.  VASRD only ratings IAW VASRD §4.14 (avoidance of pyramiding) and VASRD policy allowed dual rating of the knee for instability plus painful motion or limited ROMs.  This case justified Board consideration of separate ratings for instability and painful motion as established by formal VA policy in effect at the time of separation (General Counsel Opinion of 1 July 1997 and Fast Letter 04-22 of 1 October 2004).  

The Board adjudged that the Service exam had the highest probative value for rating.  The Board deliberated if the CI’s right knee disability picture at separation warranted a 20% instability rating (5257) plus a 10% painful motion rating (5010-5003 IAW VASRD §4.59, painful motion or under 5259 for meniscal symptoms which include painful motion).  

The CI had “occasional mechanical symptoms” with no complaints of instability and the mechanical complaints may have been attributable to meniscal injury rather than ligament laxity (ACL).  There was no giving way and there was a firm end-point to the 2+ Lachman’s test (with no instability noted at the post-separation VA exam).  Rating IAW VASRD only for instability would be closer to the “mild” 10% rating for instability, and there was insufficient evidence to support a 20% instability rating IAW VASRD only criteria.  The meniscal signs and crepitus would warrant a 10% rating IAW VASRD §4.59 (painful motion), §4.40 (functional loss) and §4.45 (the joints).  There was insufficient evidence of frequent episodes of “locking” and effusion into the joint for a 20% meniscal rating under disability code 5258.  
VASRD only rating and coding of the right knee would be 10% for instability plus 10% for painful motion.  Although there was no pathway to any combined rating higher than the 20% awarded by the FPEB, or benefit to the CI from changing the coding of the knee condition, the Board unanimously recommended changing the coding to be IAW VASRD only criteria and recommended 10% coded 5257 plus 10% coded 5010-5003 for a combined 20% disability rating.  

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.  As discussed above, PEB reliance on DoDI 1332.39 for rating the right knee condition was operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the right knee condition, the Board unanimously recommends dual knee rating with disability ratings of 10%, coded 5257 (instability); plus 10%, coded 5010-5003 (painful motion) 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:  

CONDITION	VASRD CODE	RATING	
Right Knee Pain S/P ACL…(With Chondromalacia)	5257	10%	
	5010-5003	10%	
COMBINED	20%	

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-2014-02808.

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,

XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive  
2.  Record of Proceedings  

cc:
SAF/MRBR