RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00167
BRANCH OF SERVICE:  Air force	SEPARATION DATE:  20060314

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aerospace Maintenance Journeyman, medically separated for “chronic right knee pain status post…ACL repair and partial meniscectomy with persistent osteochondral defect” with a disability rating of 20%.

CI CONTENTION:   The rating for the right knee did not reflect the Veterans Affairs Schedule for Rating Disabilities in effect at the time of separation and should have been higher.  Restless leg syndrome was diagnosed as sleep apnea by the VA.  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 - 20051216	VARD - 20061027	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain…	5257	20%	Traumatic Injury…Right Knee…	5260	20%	20060711	
Restless Leg Syndrome	Not Unfitting	Restless Leg Syndrome	8599-8520	0%	20060711	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Chronic Right Knee Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in August 1998 while playing basketball.  In February 1999, he underwent right knee surgery for an anterior cruciate ligament (ACL) tear and a meniscal tear with hardware removal of a transfixation screw in October 2000.  In July 2003, a second meniscectomy was performed for a medial meniscal tear and grade 3 chondromalacia of the medial femoral condyle.  

At a physical therapy (PT) consultation in April 2004, the CI reported persistent right knee pain.  In April 2004, X-rays demonstrated a 1-cm distracted osteochondral defect of the medial femoral condyle and stable old posttraumatic/surgical changes.  At an orthopedic visit in July 2004, the CI complained of popping, locking, swelling, and giving out of his right knee.  In October 2004, he had cartilage repair of the medial femoral condyle and microfracture of the trochlea.  

At a 5 January 2005 PT evaluation, right knee range of motion (ROM) was 130 degrees (normal 140) flexion and 0 degrees extension (normal).  On 12 January 2005, X-rays revealed a stable knee status post ACL repair with a small 1-cm irregularity along the medial femoral condyle consistent with an osteochondral lesion seen on MRI in 2002.  

At an orthopedic visit on 4 May 2005, the CI complained of popping, swelling, and buckling of the right knee.  The examiner assessed “osteochondral defect failed osteoarticular transfer system procedure” which was confirmed by MRI findings.  On 6 June 2005, the CI reported that he twisted his knee while walking downstairs.  X-rays the same day demonstrated mild lateral patellar subluxation and a small joint effusion.  

The 14 June 2005 MEB NARSUM examination, 9 months prior to separation, noted complaints of persistent right knee pain rated at 3-9/10 with popping, locking, swelling, and giving out.  Physical examination showed right knee flexion to 120 degrees and extension to 0 degrees; painful motion was not addressed.  There was slight right quadricep atrophy and positive lateral joint line tenderness, but instability and meniscal testing were negative.  The examiner recommended continued non-steroidal anti-inflammatory drugs for pain relief, as well as an ambulatory assistive device and medial unloader brace.  On 24 June 2005, the CI received a steroid/anesthetic injection for knee pain secondary to degenerative joint disease and osteochondritis dissecans.  

At a family practice appointment on 23 February 2006, less than 1 month before separation, the CI complained of chronic right knee pain.  Physical examination revealed no knee abnormalities and full ROM; painful motion was not addressed.  There was no crepitance (grinding sensation), knee laxity or joint pain.  On 12 October 2005, the CI was fitted for an unloader knee brace.  

At the 11 July 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported bilateral knee pain and right knee locking.  He used a right knee brace and occasionally a cane.  Physical examination showed flexion to 88 degrees, and then to 84 degrees with repetition.  Extension was 0 degrees, with crepitus, popping and painful motion during all ROM measurements.  There was mild lateral instability, normal medial stability, and negative drawer (to determine laxity) and meniscal testing. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 20%, coded 5257 (knee, other impairment-moderate), citing Department of Defense regulations and the VASRD.  The VA rated the right knee condition 20%, coded 5260 (leg, limitation of flexion), based on the C&P evaluation 4 months after separation, citing limitation of motion and moderate pain.  Members agreed the CI’s right knee was symptomatic at the time of separation, and supported a 20% rating under diagnostic code 5258 (cartilage (meniscus), semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint), documented by the preponderance of STR and VA evidence.  There was no knee instability to support a 10% rating under code 5257, albeit the PEB assigned a 20% rating for moderate disability, which was not documented proximate to separation.  There was no limitation of motion to support a rating under the codes for limitation of flexion or extension (5260, 5261) prior to separation, although 4 months post-separation there was a decrease in flexion to 88 degrees without evidence of intercurrent injury, accident or surgical hardware failure.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  Although the CI did have a meniscus (semilunar cartilage) removal, which was symptomatic (code 5259), the panel agreed that the pain was already a component of code 5258 criteria noted above; and if applied, would invoke pyramiding IAW §4.14 (avoidance of pyramiding).  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 right knee condition.

Contended PEB Condition: Restless Leg Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  A note dated 15 December 2004, indicated the CI had an onset in the prior couple of months of odd sensations in the left leg with a sudden urge to shake/jerk the leg.  It occurred at rest and significantly during the night.  The diagnosis was restless leg syndrome and pramipexole (a dopamine agonist) was prescribed for treatment.  The pramipexole was not tolerated due to dry mouth, although the CI did notice significant improvement during the day, but not at night.  The CI was referred to neurology for another medication option.  At the C&P evaluation, 4 months after separation, he reported using gabapentin (for nerve pain), but was unsure whether it had decreased the symptoms.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for contended condition; and so, no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended restless leg syndrome condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were 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 20161231, 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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01658.

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,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings