RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00126
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Pavement and Construction Equipment Apprentice, medically separated for “chronic right knee pain status post right knee surgery for anterior cruciate ligament and meniscal tear,” with a disability rating of 10%.  

CI CONTENTION:  The CI asserts he received a 20% rating from the VA at discharge which has since been raised to 90% due to his inability maintain employment.  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 based upon a 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 - 20040308	VARD - 20041021	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain S/P Right Knee Surgery for ACL and Meniscal Tear	5257	10%	Right Knee S/P ACL Reconstruction and Meniscectomy	5259	10%	20040917	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right knee surgery in May 2002 for anterior cruciate ligament (ACL) reconstruction with patellar tendon graft and medial meniscus repair.  Due to poor rehabilitation progress, the CI underwent a second surgery in March 2003 for a lateral meniscus stabilization and medial meniscal repair.  Persistent knee pain led to a third surgery in December 2003 for further meniscal repair.  Following this third surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right knee pain” for PEB adjudication.  

At the orthopedic clinic visit on 5 January 2004 (1 month after the December 2003 surgery and 3 months before separation), the CI reported an episode of “catching, clicking” followed by pain, just prior to the examination.  The examiner noted the CI’s pain had improved (particularly noting less pain in a sitting position).  The physical examination showed minimal anterior cruciate ligament (ACL) instability (grade 1 to 2 Lachman), negative drawer and pivot shift, with no lateral instability (medial and lateral collateral ligaments intact).  There was no effusion, however some bulging was noted laterally.  Overall, the examiner summarized the findings as “quite a benign” evaluation.  

At the MEB NARSUM examination on 30 January 2004 (2 months before separation), the CI reported intermittent crutch use for walking.  The physical examination showed bilateral joint line tenderness and mild generalized swelling.  There was full range of motion (ROM) with pain and no evidence of instability.  At a primary care visit on 5 April 2004 (2 days before separation), the physical examination showed bilateral joint line tenderness without effusion, and full ROM.  Testing of ACL and meniscal integrity were normal, while other testing indicated joint capsule or ACL laxity, or damage to the lateral and medial collateral ligaments.  

At the 17 September 2004 VA Compensation and Pension (C&P) evaluation (5 months after separation), the CI reported constant knee pain which did not cause incapacitation.  Functional impairment was related to standing and walking however the condition did not result in any time lost from work.  The CI’s gait was normal and he required no assistive devices for ambulation.  Physical examination showed crepitus, but no instability.  The ROM was 0-140 degrees (normal) and there were no further limitations after repetition due to pain, fatigue, weakness, lack of endurance, or incoordination.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5257 (knee, other impairment of:  recurrent subluxation or lateral instability).  The VA rated the right knee condition 10%, coded 5259 (cartilage, semilunar, removal of, symptomatic), based on the VA C&P examination 5 months after separation.  The Board considered the evidence for rating.  There was no limitation of motion which supported a higher 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).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under the respective codes.  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  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).  

In considering support for a higher rating, the Board noted the PEB’s choice of the 5257 code for the possible presence of instability.  The examinations proximate to separation did not consistently demonstrate the presence of ligamentous instability or laxity.  The CI complained of “catching” or “clicking” at the January 2004 orthopedic examination and this examiner recorded a grade 1 to 2 Lachman result.   The April 2004 primary care examination 2 days prior to separation reported a positive varus and valgus test.  However, all other examinations noted the presence of intact ligaments. Board members debated the significance of the orthopedic examination’s minimally positive Lachman test while other examinations noted a negative test.  The Board considered the NARSUM and VA examinations proximate to separation as having the highest probative value as they were most complete, and VASRD compliant as compared to the primary care examination proximate to separation.  The January 2004 orthopedic examination was 1 month after surgery and thus had less probative value than the NARSUM and VA examinations which were further removed from the third surgery as noted.   The Board concluded that there was insufficient evidence of ligament instability to support dual coding under 5003 and 5257.  There was 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, 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 chronic right knee condition.  

BOARD FINDINGS:  In the matter of the chronic right knee pain 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 20150203, 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-2015-00126.

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