RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00726
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Journeyman, medically separated “chronic right knee pain,” with a disability rating of 10%.  

CI CONTENTION:  “After being discharged from the military I had to have another surgery on my right knee.  I still have problems with it today”.  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 - 20040616	VARD - 20050202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Knee Pain Status Post Arthroscopy	5003-5299	10%	Right Knee Degenerative Joint Disease With Patellofemoral Pain Syndrome	5260	10%	20041101	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Knee Pain Status Post Arthroscopy.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain condition began in October 2001 and recurred in January 2002  when she stepped on a rock and twisted her right knee.  She again experienced pain in the right knee in February 2002.  Treatment included Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), rest, ice, compression and elevation (RICE), and stretches.  At an orthopedic evaluation on 1 July 2002 the CI was found to have a positive McMurray test (to determine a meniscal tear).  The CI underwent right knee surgery arthroscopy on 18 July 2002 at which time no meniscal tear was noted and a plica resection (to remove a portion of the synovial membrane) was performed.  

At the time of the physical therapy appointment on 2 August 2002, 1 month post-surgery, the examiner recorded the CI had reduced knee flexion, reduced strength, moderate edema (swelling), and an antalgic gait (to avoid pain).  At a follow-up appointment on 22 August 2002, the examiner recorded steady improvement of the right knee range of motion (ROM), strength, and gait.  At the physical therapy appointment on 20 September 2002, the examiner noted a normal gait with no edema/effusion (swelling), and that the CI could perform a full squat.  At an orthopedic examination on 20 November 2002, the examiner noted a full ROM and no laxity of the right knee with tenderness at the lateral femoral epicondyle (a protrusion on the lower outside of the femur).   At an orthopedic examination on 11 April 2003, the CI complained of a twisted knee with mild swelling after climbing out of a truck 3 days earlier.  The examiner recorded no effusion or laxity.  McMurray’s test was positive, but ligamentous structures were intact, and the knee was tender along the medial joint line.  The examiner considered a medial meniscus tear versus a recurrent plica.  At physical therapy on 23 April 2003, the examiner noted swelling at the patellar tendon, but no bruising.  There was tenderness along the medial/lateral joint line and patellar tendon, but patellar mobility was good.  Testing for ligamentous instability and a meniscal tear were negative.  At the 2 June 2003 orthopedic examination, the CI complained of sharp pain rated as 4/10 (10 being the worst pain) in intensity.  The examiner recorded tenderness along the medial joint line, but no laxity.  

On 9 July 2003, the CI underwent an orthopedic evaluation and complained of right knee pain and four episodes of “giving away” where the knee actually buckled.  On examination there was a normal gait, ROM of 0-130 degrees, and “a little bit” of medial and lateral joint line tenderness.  McMurray’s testing was negative for any clicking or popping, but there was some pain medially.  There was “a little bit” of laxity on the right side compared to her left side, which the examiner recorded as 5 millimeters of movement, which was 1+.  On 11 July 2003, magnetic resonance imaging (MRI) revealed a normal postoperative knee without anterior cruciate ligament (ACL) or medial meniscus tears.  At a follow-up orthopedic examination on 17 July 2003, the examiner noted the possibility that the medial joint pain could be from parapatellar soft tissue swelling from an enzymatic release of cytokines (proteins involved in an immune response) from an articular cartilage defect, although the MRI did not show a defect.  An injection of a steroid and anesthetic was given in the medial aspect of the tibia and hamstrings and Bextra (valdecoxib, an NSAID) was prescribed.  A 23 February 2004 bone scan revealed no focally intense regions that would indicated a fracture or abnormal bone metabolism.  On 23 February 2004 the CI reported a buckling episode for which a knee sleeve was prescribed.  

The 26 April 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic knee pain that resulted in decreased tolerance of normal activities.  Physical examination based on orthopedics examinations of 10 and 25 February 2004 revealed the CI had a full ROM and normal gait.  There was no effusion or crepitus.  The inside of the knee and meniscal joint line were tender and a patellar grind test was positive.  Testing for ligament damage was negative, and there was no indication of tears to the meniscus or the ligaments.  Testing for patellar instability was positive with two quadrants subluxation; however, testing for damage to the cartilage under the kneecap was negative. The CI experienced pain in the inner portion of the front of the knee when squatting, but not with a deep squat.  X-rays were within normal limits.

At an orthopedic evaluation for right knee patellofemoral pain on 14 September 2004, 1 month post-separation, the CI had a positive Sage sign (indicative of loose patellar restraints) and a tight lateral retinaculum with some slight popping about the kneecap with passive ROM.  The CI underwent arthroscopic surgery consisting of a chondroplasty of the patella and a lateral release on 1 October 2004, 2 months after separation, for an articular cartilage defect with an unstable flap of the medial facet of the patella and grade 2 articular fissures of the lateral condyle and trochlear groove.  

At the 1 November 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported wearing a knee brace since her arthroscopy in October 2004.  She complained of pain at a 4/10 level.  The CI denied flare-ups, swelling, or stiffness.  She could walk several miles, but did have some soreness afterwards.  Physical examination revealed still healing surgical scars.  There was no evidence of an effusion.  There was mild tenderness over the patella, but no instability was noted, and posture and gait were normal.  The examiner reported there was no additional functional limitation of the right knee.  ROM was from 0 to 140 degrees with minimal tenderness during flexion-extension maneuvers with no instability.  The examiner reported right knee x-rays were normal.  On 8 November 2004, 6 weeks postoperatively, the CI had no pain; the patella tracked nicely; the knee was benign; and she ambulated without a limp. 

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Knee ROM
(Degrees)	Ortho 13 Mos. Pre-Sep
	MEB 4 Mos. Pre-Sep
	VA C&P 3 Mos. Post-Sep
	
Flexion (140 Normal)	130	“FROM”	140	
Extension (0 Normal)	0	“FROM”	0	
Comment	Painful motion; tenderness 	Painful motion; + patellar grind; tenderness	“Some tenderness”	
§4.71a Rating	10%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right knee pain condition 10%, coded 5003-5299 (arthritis, degenerative).  The VA rated the chronic right knee pain condition 10%, coded 5260 (leg, limitation of flexion), based on the C&P examination 3 months after separation, citing tenderness with ROM of the right knee.    

There was no limitation of motion which supported a 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) as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257).  The CI did undergo a chondroplasty for articular cartilage tears; however, a 10% rating using code 5259 (cartilage, semilunar, removal of, symptomatic) offers no benefit to the CI.  However, prior to surgery, the CI did report episodes of buckling, although the frequency was limited to about five reported episodes, which did not reach the level of frequent locking nor were there recurrent effusions (5258) to warrant a 20% rating, although there was pain on a regular basis.  Additionally, at the post-separation surgery, there was an unstable flap of the medial facet of the patella, which was removed.  However, 6 weeks postoperatively, the CI was pain free and well healed.  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 chronic right knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic right knee pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20160913, 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-2016-00726.

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