RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02271
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Aircraft Armament Systems, medically separated for “pain multiple joints, associated with osteonecrosis and suspected osteochondritis dessicans” with a disability rating of 10%.  

CI CONTENTION:  The CI contends his condition continues to worsen and negatively impact his daily activities.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20070621	VARD - 20080508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Multiple Joints Associated with Osteonecrosis and Suspected Osteochondritis Dessicans	5099-5003
	10%	S/P Right Knee Surgery with Osteochondritis Dissecans and Scar 	5009-5260	10%	20080219	
			Left Elbow Osteochondroma and Avascular Necrosis with Scar 	5009-5211	0%	20080219	
			Right Elbow Osteochondroma and Avascular Necrosis with Scar 	5009-5211	0%	20080219	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Pain Multiple Joints Associated with Osteonecrosis and Suspected Osteochondritis Dessicans (OCD).  The PEB combined the bilateral elbows, the right knee and the right 2nd metatarsal phalangeal (MTP) joint conditions as a single unfitting condition coded analogously to 5003 and rated 10%. The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.   The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right knee, right elbow, left elbow and right 2nd MTP conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history of right knee pain and bilateral elbow pain for approximately 8 years.  The CI underwent arthroscopy of the right knee for a presumed OCD in 1999, 3 years prior to service.  Then in November 2004 the CI underwent arthroscopic surgery for removal of free bodies in both elbows.  The CI had an injury to his right foot in September 2005 and on the X-Ray it was incidentally noted that there was flattening of the metatarsal head which was speculated to  be a sequelae of prior trauma, infarct or developmental.  Later, the CI developed pain in the area of the 2nd MTP joint.  In August 2006 he reinjured his right knee and was diagnosed with two large areas of osteonecrosis.  

Right Knee.  The 19 April 2007 MEB NARSUM examination, 8 months prior to separation, noted complaints right knee pain. The CI complained of mechanical catching in the knee with no frank locking present during the examination.  The right knee range of motion (ROM) was described as full with some mild crepitus particularly with varus stress.  According to the STR, the CI underwent two right knee surgical procedures after the MEB and PEB.  The first procedure was in July 2007 for removal of massive loose body of osteochondral defect medial femoral condyle and lateral femoral condyle.  The second procedure was in September 2007 for open bone scaffolding and bone plug of the right femoral condyle.  At the 26 November 2007 physical therapy appointment, the CI reported he was pain-free and the right knee ROM following repetitive movement was flexion of 152 degrees (normal 140) and extension +3 degrees (normal 0) with no pain reported with motion.  

At the 19 February 2008 VA Compensation and Pension (C&P) evaluation, approximately 2 months after separation, the CI reported subjective right knee weakness, stiffness and giving way without associated pain.  At the time of the C&P examination he was not treated for his knee condition.  The physical examination showed ROM was normal and recorded as flexion of 140 degrees (normal) and extension of 0 degrees (normal) without pain, fatigue, weakness, and lack of endurance or incoordination.  After repetition there was no additional limitation in motion, but there was pain.  

The panel first considered if the right knee pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement did not specifically implicate any of the unfitting medical problems; however, did mention “locking joints” and the impact they would have on the CI performing his military specialty.  The permanent profile does not list any conditions but is very restrictive with respect to physical activity.  The panel found that the CI had been intermittently restricted from physical fitness testing for several years and that this condition would have made it difficult if not impossible to deploy to an austere environment.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the overall “pain multiple joints, associated with osteonecrosis and suspected OCD,” condition 10%, coded 5099-5003 (arthritis, degenerative), citing normal ROM.  The VA rated the right knee condition 10% dual coded 5009-5260 (arthritis, other types and leg limitation of flexion), based on the VA C&P examination 2 months after separation, citing ROM was limited by pain.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture with 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 addition, there was no evidence of painful motion with functional loss supporting a minimum rating based on §4.59, §4.40 and §4.45.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee OCD condition.  

Bilateral Elbows.  The panel next considered if either elbow pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement did not implicate any specific condition.  The permanent profile does not list any conditions but is very restrictive with respect to physical activity.  The panel found that the CI was evaluated for right elbow pain and a locking sensation in April 2003 with subsequent removal of loose bodies from the joint.  After that procedure the STR is silent concerning the right elbow for 4 years until the MEB NARSUM.  Likewise, the STR was also mute concerning the left elbow from July 2005 until the April 2007 rheumatology evaluation in preparation for the MEB NARSUM.  At that visit both elbows are listed as having a history of problems but no current complaints were recorded.  In addition, at the MEB NARSUM evaluation, although the CI did complain of bilateral elbow pain he had a normal examination with no ratable features.  Therefore, the panel concluded that the preponderance of evidence showed that neither elbow condition would not have caused the CI to be referred into the DES or to be found unfit.  

After due deliberation, members agreed that the preponderance of the evidence did not support a conclusion that the functional impairment from the right or the left elbow pain condition was integral to the CI’s inability to perform his military duties, and accordingly cannot recommend a separate rating for either.  

Right 2nd MTP.  Finally, the panel considered if the right 2nd MTP pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As previously stated, the commander’s statement did not implicate any specific condition and the permanent profile does not list any conditions but is very restrictive with respect to physical activity.  The panel found that the condition was surgically treated in November 2007 and that at the time of separation and 2 months later at the VA C&P evaluation the CI had no symptoms from this condition.  Therefore, the panel concluded that the preponderance of evidence showed the right 2nd MTP condition would not have caused the CI to be referred into the DES or to be found unfit.  

After due deliberation, members agreed that the preponderance of the evidence did not support a conclusion that the functional impairment from the right 2nd MTP pain condition was integral to the CI’s inability to perform his military duties, and accordingly cannot recommend a separate rating for either.  

BOARD FINDINGS:  In the matter of the right knee osteonecrosis with suspected OCD condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  

In the matter of the right elbow osteonecrosis with OCD condition the panel unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  

In the matter of the left elbow osteonecrosis with OCD condition the panel unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  

In the matter of the right 2nd MTP osteonecrosis with OCD condition the panel unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  

There are no other conditions within the panel’s scope of review for consideration.  

The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150810, 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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02271.

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.  The Board recommended no re-characterization or modification of your separation.

I 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.  I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings