RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03075
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150616
Separation Date:  20011203

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) medically separated for left knee pain.  The left knee condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The “left knee pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “left knee pain status post (s/p) December 2000 arthroscopy and subsequent March 2001 open reduction and internal fixation (ORIF) of osteochrondral defect” as a Category I unfitting condition, rated 10%, citing application of the DoDI and Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI initially made no appeals and was medically separated.  He subsequently attempted to change his determination to elect a formal board, but his request was denied.

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:

IPEB – Dated 20010925	VA* - (~4 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain …	5003-5299	10%	Left Knee Condition	5299-5257	10% 	20020401	
Other x 0 (Not In Scope)	Other x 7	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20020603 (most proximate to date of separation [DOS]) and 20020829.
Subsequent VARDS saw temporary 100% ratings (for multiple additional surgeries), changed disability code, and a 30% rating from 20030901 and after convalescent ratings.

ANALYSIS SUMMARY:

Left Knee Pain Condition.  The CI developed left knee pain with popping and a feeling of give away on 6 July 2000.  A left knee magnetic resonance imaging performed on 14 August 2000 demonstrated an osteochrondral (bone and cartilage) injury that involved the medial femoral condyle.  The CI had a left knee diagnostic arthroscopy in December 2000.  He continued to report persistent locking symptoms and had a left knee ORIF on 9 March 2001.  He underwent physical therapy; however, he reported worsening knee pain with exercises.

The MEB narrative summary (NARSUM) exam approximately 3 months prior to separation documented complaint of constant left knee pain rated at 7/10 (worse with bending and going down steps) and significant knee limitations.  The examiner documented that the CI had been on profiles since his initial injury in July 2000 and had been unable to perform in his AFS.  He was scheduled for a repeat arthroscopy in October 2001.  The MEB NARSUM physical exam findings are summarized in the chart below.  The CI did undergo an arthroscopy on 11 October 2001.  Despite the October surgery, the CI continued to report significant pain and give away of the left knee.

The VA Compensation and Pension (C&P) exam approximately 4 months after separation documented that the CI reported that he had continuous knee pain, his knee locked up and would give out and he needed to wear a brace which caused him to favor his right knee.  The VA C&P physical exam documented the CI had a normal gait and was “able to walk on his toes, but not able to walk on his heels secondary to his left knee condition.”  Knee findings are summarized in the chart below.  A left knee X-ray performed at this exam showed an irregularity at the medial condyle.  A handwritten C&P Addendum clarified the left knee diagnosis from “left knee pain” to “residuals of left knee fracture with ORIF.”

A VA Orthopedist treatment note in January 2003 (13 months after separation) documented pain with ambulation, slight limp on the left side and tenderness anterior to the medial joint.  A left knee X-ray showed an osteochrondral defect with irregularity in the medial femoral condyle and some squaring off.  The examiner recommended an osteochrondral graft (surgery was performed in July 2003; 19 months after separation).

There were goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Knee ROM
(Degrees)	MEB ~3 Mo. Pre-Sep	VA C&P ~4 Mo. Post-Sep	
Flexion (140 Normal)	“Approximately 120”	120	
Extension (0 Normal)	--	--	
Comment:  Surgery 2 Mo. Pre-Sep and 20 Mo. Post-Sep	Medial joint line tenderness; valgus stress produces pain; Lachman’s and anterior drawer signs are negative (no instability)	No pain on ROM; no laxity; no anterior drawer sign; left calf circumference 17.5 inches right calf 18 inches;	
§4.71a Rating	10%	10% (VA deferred)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition at 10%, coded analogously to 5003 (Arthritis, degenerative [hypertrophic or osteoarthritis]).  The VA rated the left knee condition at 10%, coded as 5299 analogous to 5257 (Knee, other impairment).  The VA later changed the code to 5260 [Leg, limitation of flexion].  There was ample evidence that the CI’s left knee had limited motion and pain with activity proximate to separation.  Despite three extensive knee surgeries, the pain was not resolved.  Although the CI complained of instability-like symptoms, there was no objective evidence of knee laxity, subluxation or instability proximate to separation for coding (or dual knee coding) under 5257.  Analogous meniscal cartilage coding under 5259 was considered, but would include painful motion and not benefit the CI.  Higher rating under 5258 (Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) was not supported.  Application of VASRD §4.59 (painful motion) warranted a 10% rating for the knee for painful motion.  The after separation surgeries and increase of knee symptoms were adjudged after separation worsening and not indicative of the CI’s disability picture proximate to separation.  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 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 20140530 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-2014-03075.

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

cc:
SAF/MRBR