RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00493
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20081215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Security Forces Journeyman, medically separated for “left chondromalacia patella” (CMP) with a disability rating of 10%.  

CI CONTENTION:  The CI contended her back and feet.  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 - 20081104	VARD - 20100708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left CMP	5099-5003	10%	L Knee, S/P Arthrotomy w/ Scar	5260	0%	20100416	
Plantar Fasciitis	5310	Cat II	Bilateral Pes Planus with Plantar Fasciitis	5276	10%		
Scoliosis	5299-5239	Cat II (EPTS)	Scoliosis, Thoracolumbar Spine	5299-5239	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Knee.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI deployed in 2005.  On the post-deployment interview date 6 October 2005, she reported that she had been seen for a “cold”, but denied other issues.  On 26 June 2006, she was seen for a post-deployment examination and for follow up of a foot and ankle injury and a left knee injury sustained while deployed.  She was noted to have full range of motion (ROM) of both knees without effusions (fluid) and the ankles were stable.  
Her gait was normal.  In orthopedics on 15 January 2007, it was noted that she injured her left knee in March 2006 while deployed and had been treated with a knee immobilizer and then a brace.  An MRI reportedly showed a cartilage defect of the kneecap (patella) which was confirmed by a second MRI.  On examination, she had a positive patellar grind (pain from forceful movement of the kneecap), but a full ROM and stable ligaments.  She was treated with an injection (not specified).  Her pain persisted despite treatment and she had a knee realignment procedure.  She was then entered into rehabilitation, but had persistent pain which precluded full duty.  She was then referred for an MEB.  

The MEB NARSUM examination performed on 31 January 2008, 11 months prior to separation, noted complaints of increased pain and swelling.  The CI had a limp.  The physical examination showed 108-110 degrees of flexion with mechanical limitation.  It was documented that the CI was slowly making progress.  

In family practice on 11 August 2008, it was noted that her left knee pain interfered with her military duties.  The CI was noted to have “obvious atrophy in calf and thigh muscles”, but had full ROM with stable ligaments and no effusion.  The same examiner recorded that the gait was normal and no muscle dysfunction was present (the panel could not explain this inconsistency).  

The CI was seen in orthopedics on 26 January 2009, 6 weeks after separation, for back, shoulder, and knee pain.  It was noted that compression of the knee was painful, but that the ROM was full and the knee stable.  The gait was abnormal, but it was not specified why.  On follow-up for a joint injection (Synvisc) 2 months later, the gait and stance were normal.  

At the VA Compensation and Pension (C&P) evaluation performed on 16 April 2010, 16 months after separation, the CI reported “weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability, deformity, tenderness, drainage, effusion, subluxation, pain and dislocation.”  The physical examination showed a normal gait without use an assistive device.  The left knee showed no signs of swelling, instability, effusion, weakness, tenderness, malalignment, subluxation or guarding.  The ROM was normal and painless.  An X-ray was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5099-5003 (degenerative arthritis).  The VA rated the left knee condition 0%, coded 5260 (leg, limitation of flexion), based on the C&P examination 16 months after separation, citing leg flexion limited to 60 degrees.  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.  The panel noted that the VA examination 16 months after separation was outside of the usual 12 month window of higher probative value of VA evidence for the panel’s rating recommendation at permanent separation.  It did show that the CI made a full recovery as was expected prior to separation.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  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).  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 panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.  

Contended PEB Condition:  Back (Scoliosis) and Feet (plantar fasciitis).  The panel’s main charge with respect to its recommendation is an assessment of the fairness of the PEB’s determination that the contended conditions were not unfitting.  
Neither of the conditions was cited in the duty limitation report, specifically implicated in the commander’s statement, nor judged to fail retention standards.  The panel also noted that although the CI reported a several year history of foot pain, the first clinical record in evidence specific for the feet was a podiatry evaluation on 13 August 2008, over 6 months after entry into the MEB process.  There is a presumption of fitness IAW DoDI 1338.32 E3.P3.5.  Regarding the back pain, the record clearly shows that significant scoliosis was identified on X-ray and by the MEPS examiner prior to accession.  There were no clinical records found indicating significant back pain until after entry into the MEB process.  Again, there is a presumption of fitness aside from the existed prior to service (EPTS) adjudication by the PEB.  The panel did not find evidence to support permanent service aggravation of this EPTS condition and the PEB adjudication is supported by the record.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended scoliosis (back) and plantar fasciitis (feet) conditions, the panel unanimously recommends no change from the PEB determination as Category II conditions.  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 20100125, with attachments
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-2016-00493.

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