RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01235
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Health Services Management Craftsman, medically separated for “chronic left knee pain” with a disability rating of 10%.   

CI CONTENTION:  “Knee pain makes it difficult to work full time, migraine continue to increase & cause pain, blurred vision speech problems all others attached.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040203	VARD - 20050307	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5257	10%	Post-Operative Residuals of Left Patellar Lateral Release and Total Synovectomy	5099-5019	10%	20040706	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment record and MEB narrative summary (NARSUM), the CI had a lengthy history of left knee pain.  She underwent arthroscopic surgery and a lateral release in 2000 and a subsequent excision of a left knee neuroma in the area of the left lateral patellar retinaculum in April 2002.  Pathology revealed fibrous tissue and post-operatively she developed pain and swelling about the knee.  On 25 May 2002, she underwent left knee arthroscopy with irrigation and a near complete synovectomy.  A physical therapy summary on 12 November 2002 indicated that after approximately 5 months, the CI continued to have range of motion (ROM) limitations and pain with functional activities.  Her knee flexion in October was a maximum of 128 degrees (normal 140).  

At an orthopedic clinic visit in January 2003, left knee ROM was 0-100 degrees with crepitus (grinding sensation) and a lateral riding patella.  At the 14 April 2003 orthopedic examination, 10 months post-surgery and 12 months prior to separation, the CI complained of continued left knee pain with prolonged use and weather changes.  Physical examination noted some crepitus with mild swelling and a trace effusion. There was mild discomfort to palpation of soft tissue around the knee.  Left knee ROM was 0-130 degrees.  Orthopedic evaluation on 22 July 2003 noted knee pain with prolonged use and weather changes as well as numbness around the knee.  Measure ROM was 0-130 degrees with decreased sensation of the left anterolateral knee.  

The 27 October 2003 MEB NARSUM examination, 17 months post-surgery and 5 months prior to separation, noted complaints of left knee pain with prolonged activities such as standing or walking.  The CI reported she was unable to run and had difficulty squatting, climbing stairs, and kneeling.  Her symptoms and function improved with use of a cane.  Physical examination showed well-healed arthroscopy incisions, which were non-tender and no effusion was noted.  The left knee was stable to ligamentous examination and there was mild lateral tracking of the patella.  ROM measurement of the left knee was 0-130 degrees; painful motion was not mentioned.  

At the 6 July 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported constant left knee pain rated at 3-5/10.  The pain occasionally woke her up from sleep and weather changes made the pain worse.  Prolonged walking required use of a cane for support and balance, and she occasionally used a patellar brace for long walks.  Walking in excess of 45 minutes caused pain to increase to 10/10 and necessitated use of a wheel chair.  Functional impairment regarding her left knee involved anything that required weight bearing as well as climbing stairs, squatting, and kneeling; however, she denied any locking or instability other than that related to pain.  Physical examination showed a normal gait and posture and no assistive device for ambulation.  The left knee showed no signs of heat, redness, swelling or effusion.  Crepitus was noted as well as positive patellar apprehension.  The ROM was 0-130 degrees, and pain was noted at the end range of flexion, but there was no fatigue, weakness, lack of endurance, incoordination, or ankylosis.  Drawer and McMurray tests, to determine laxity and a meniscal tear respectively, were negative.  There was bilateral retropatellar crepitation, worse on the left than the right, and left side positive patellar apprehension.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left knee pain 10%, coded 5257 (knee, other impairment of: recurrent subluxation or lateral instability: slight).  The VA also rated the chronic left knee pain 10%, coded 5099-5019 (bursitis), based on the C&P examination, citing pain, limited motion and functional loss due to pain.

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).  It was agreed that frequent locking due to dislocated semilunar cartilage was not present, and therefore a 20% rating was not justified under the 5258 code.  Members noted that the PEB rated the knee condition at 10% under VASRD coding for instability, yet the PEB cited “knee pain” implying the left knee condition was rated using painful motion/functional loss criteria (code 5019 is rated using code 5003).  The panel considered whether dual coding for painful motion and instability was reasonable.  In deliberating a rating under the 5257 code (knee, other impairment of; recurrent subluxation or lateral instability), the panel considered the CI’s claim for using a cane for prolonged walking.  However, no other evidence was available to show use of assistive devices during ambulation or normal use of the left knee prior to separation.  Although objective findings by the NARSUM examiner showed mild patellar tracking, there was no ligamentous instability and no other examinations documented no more than mild left knee instability.  Painful motion was mentioned at the VA examination, where the CI’s gait was noted as normal, but not at the NARSUM examination.  The VA examiner did not find any evidence of laxity, whereas the NARSUM examiner noted mild tracking of the patella.  Thus, the 10% rating by the PEB and the 10% rating by the VA each have credence, but to dual rate the CI’s condition is not acceptable since there was approximately 8 months between the NARSUM and VA examinations and neither examination independently could support a dual rating.  The panel adjudged that there was insufficient evidence of painful motion proximate to separation to support dual coding under 5257 and 5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic left knee condition.    

BOARD FINDINGS:  In the matter of the chronic left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel, recommends 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 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01235.

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