RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03844
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20061120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Armament Systems Journeyman, medically separated for “chronic ankle pain…” and “chronic left knee pain…”, each rated 10%, with a combined disability rating of 20%.

CI CONTENTION:  The CI indicates her knee and back pain continue to get worse and are affecting other joints, including her hips and right knee.  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 - 20061003	VARD - 20070516	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Ankle Pain…	5311	10%	Tarsal Tunnel Syndrome, Left…	5271	10%	20070331	
Chronic Left Knee Pain…	5099-5003	10%	Bursitis, Left Knee…	5260-5019	10%		
Chronic Low Back Pain	Cat II	Lumbar Strain	5237	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured her left ankle in a motor vehicle accident in April 2005.  Pain persisted and magnetic resonance imaging (MRI) demonstrated a bone contusion (distal talus) and “very mild” tendon injuries (posterior tibial and peroneus brevis) which were not judged to require surgical intervention.  There were various STR entries that documented grossly normal range of motion (ROM).  There was no STR evidence for more significant ROM limitation, persistent gait disturbance, joint instability or impingement, or malalignment.  The STR reflected an improving clinical course, although insufficient to allow unrestricted duty; and, the CI was referred for an MEB which in turn forwarded “left ankle pain” to the PEB.  

At the MEB NARSUM examination dated 16 June 2006 (5 months before separation), the CI reported chronic left ankle pain resulting in an inability to run, stand for more than 15 minutes, lift more than 20-30 pounds, squat down, or walk for long distances.  The physical examination recorded some areas of tenderness but “full” ROM.

At the VA Compensation and Pension (C&P) examination on 31 July 2007, performed 4 months after separation, the CI reported “constant pain with walking and standing for a long time.”  The physical examination recorded a normal gait and the absence of an effusion without comment regarding tenderness.  Measured ROM was dorsiflexion to 10 degrees (normal 20) and plantar flexion to 40 degrees (normal 45), specifying painful motion. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated 10%, coded 5311 (Group XI muscle code for plantar flexion).  The VA rated 10% under code 5271 (ankle, limited motion), citing “moderate” limitation; and, 5271 offers a 20% rating for “marked” limitation.  The PEB’s muscle coding was reasonable given the tendon injuries, and 5311 was the clinically appropriate choice.  The PEB’s 10% rating was consistent with “moderate” disability under 5311; and, 5311 offers ratings of 20% for “moderately severe” and 30% for “severe” disability.  Members agreed that there was insufficient evidence for the requisite cardinal signs and functional impairment to justify a rating higher than 10% under criteria of VASRD §4.73 (muscle disabilities); and, considered whether a higher rating could be supported under criteria of VASRD §4.71a (musculoskeletal system).  Members agreed that the ROM evidence did not support the higher rating under 5271; and, given the absence of ankylosis, nonunion or malunion, §4.71a offers no applicable joint code which would yield a rating higher than 10% for this case.  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 of the left ankle condition.  

Chronic Left Knee Pain.  The CI injured her left knee in the same accident as above for the ankle.  An MRI was interpreted as a “contusion/nondisplaced fracture” (proximal fibula) and a meniscal tear (posterior horn).  Surgical intervention (diagnostic arthroscopy) ensued in July 2005 (14 months before separation), but no significant bone or meniscal injury was identified, and the procedure was confined to a chondroplasty (removal of damaged cartilage on the joint surface).  There were multiple STR entries noting grossly normal knee ROM; and, there were several with the same ROM measurements: flexion to 130 degrees (normal 140, 45 for minimum 10%) and extension 0 degrees (normal).  There was no STR evidence for more significant ROM limitation, persistent gait disturbance, persistent effusions, locking, or instability.  Post-operative treatment did not result in improvement sufficient to allow unrestricted duty, and the MEB forwarded “left knee pain” for PEB adjudication.

The NARSUM documented persistent pain without elaboration of severity, and functional limitations were included with those above for the ankle.  The physical examination recorded tenderness, stability to stress testing in all planes, and “full” ROM.

The 4-month post-separation VA C&P examination (same as above) documented “daily” pain with flares rated 7/10 precipitated by “walking, running, [and] standing.”  The CI also reported subjective instability and the use of a brace, although the examiner specified no subluxation or dislocations.  The physical examination recorded a normal gait, the absence of effusion, stability to stress testing, and negative signs of impingement (locking).  The ROM measurements were flexion to 125 degrees and extension of 0 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was consistent with §4.71a criteria for the ROM evidence and other ratable findings.  The VA’s 10% rating under code 5260-5019 (limitation of flexion - bursitis) cited painful motion.  There was no minimum compensable ROM limitation.  There was no persistent effusion or locking, and no fracture with non-union or malunion, to achieve a rating higher than 10% under any alternate code; and, there was no evidence of instability for separate rating.  After due deliberation, considering all evidence and with deference to reasonable doubt, the Board concluded was that there was insufficient cause to recommend a change in the PEB adjudication of the left knee condition.  

Contended Low Back Pain.  The CI injured her back in the same accident.  There were no STR entries focused on the condition, although it was mentioned in various entries addressing the ankle and knee conditions.  An MRI was normal.  The STR confirmed the absence of neurological complaints or deficits, and there was no documentation of functional limitations specifically attributed to the back.  There were a series of L profiles leading to separation which did not list the specific conditions profiled, except for one 12 months before separation which listed only the left knee and foot.  The commander’s performance statement addressed “current medical condition” without providing functional evidence specific to individual conditions.  The NARSUM stated “continues to have low back pain since the time of her injury” and included it with the “combination of medical problems” causing the functional limitations elaborated above.  The post-separation C&P examination documented normal physical findings and normal ROM measurements without painful motion, resulting in a 0% rating by the VA.

The Board’s main charge was to assess the fairness of the PEB’s determination that the lumbar condition was not unfitting.  Members agreed that there was a lack of performance-based evidence indicating that the condition interfered with duty requirements to an extent that it alone would have resulted in MEB referral and termination of service.  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 lumbar condition; thus, it is ineligible for disability rating.  

BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the contended lumbar condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140818, 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-2014-03844.

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