SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00561.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX  	CASE:  PD-2017-00561
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Airborne Mission Systems Journeyman, medically separated for “patellofemoral syndrome, right knee” with a disability rating of 10%.

CI CONTENTION:  Review all conditions.  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 - 20071012	VARD - 20080728	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Syndrome, Right Knee	5099-5003	10%	Patellofemoral Syndrome, Right Knee	5257	10%	20080211	
Laxity of Ligaments	Cat II/EPTS	Hypermobility of Multiple Joints…	5003	NSC	20080211	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Right Knee Patellofemoral Syndrome.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right knee condition began in June 2004 after rigorous physical activity.  The 30 October 2006 MEB NARSUM examination, 13 months prior to separation, recorded complaints of chronic right knee pain, ligamentous laxity and joint instability.  Physical examination showed medial patellae movement with obvious laxity from flexion to extension of both knees.  Muscle strength was 4/5 in both legs and no neurological deficits were noted.  
During an orthopedic evaluation for the MEB on 16 January 2007, 11 months before separation, the CI reported constant right knee pain aggravated by standing, bending, walking, squatting, lifting, kneeling and going up and down stairs.  He also indicated a history of loose ligaments and dislocations bilaterally.  Physical examination revealed no right knee effusion, good quad strength, and “some laxity” with instability testing (all comparable to the left knee).  Right knee extension and flexion were “full,” but painful motion was not addressed.  

At the 11 February 2008 VA Compensation and Pension (C&P) general examination, 2 months after separation, the CI reported right knee pain with running, prolonged sitting and going up and down steps.  Physical examination showed a steady and smooth gait with lower extremity muscle strength at 5/5.  Right knee flexion was to 140 degrees (normal) and extension to 0 degrees (normal) with no painful motion.  Right knee X-rays were negative for fractures or subluxations and revealed normal surrounding soft tissues.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative).  The VA also rated the right knee condition 10%, coded 5257 (knee, other impairment), based on the STR and C&P examinations, citing recurrent subluxation or slight lateral knee instability.  Members agreed there was no limitation of motion which supported a rating under the diagnostic codes for flexion or extension (5260, 5261) for either knee, and no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  While code 5259 (cartilage, semilunar, removal of, symptomatic) was applicable for both knees, a maximum 10% rating provided no benefit to the CI.  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) for either knee.  Additionally, there was no evidence of painful motion with functional loss supporting a 10% 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 there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.

Contended PEB Conditions:  Laxity of Ligaments.  The panel first considered the PEB determination that the ligament laxity condition had existed prior to service (EPTS) and was not permanently service aggravated.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence (based upon accepted medical principles as opposed to medical opinion) that the natural progression of a pre-existing condition was unaltered by any consequence of military service IAW DOD 1338.32 E3.P4.5.2.3.  Panel members noted during an orthopedic hand surgeon evaluation on 23 June 2004 (less than 2 years after entering the service), the CI reported a “several-year history of progressive pain in the wrist,” with subluxation (partial dislocation) “for as long as he can remember.”  The provider stated that he had “quite a bit of ligamentous laxity in the joints and particularly the wrist.”  In December 2004, while deployed, he had a minimum of four visits for right wrist pain where a history of congenital joint laxity was noted along with spontaneous partial dislocations and the ability to voluntarily dislocate his wrists bilaterally.  Additionally, at a 30 October 2006 evaluation to determine his aviation future, his flight surgeon recorded, “chronic dislocations of his wrists, ankles and patellae…increased ligamentous laxity from childhood, which was previously attributed to being double-jointed.”  

The panel observed that although the CI clearly had some degree of ligamentous laxity prior to entering service, there was no evidence of disability from the condition.  Therefore, panel members find it at least as likely as not that the joint laxity condition was service-aggravated, and as such recommends an additional disability rating.  The panel then considered which of the listed joints showed disability from laxity.  The first record of pain with subluxation of the left wrist was at a 10 December 2003 periodic health assessment, where the CI reported pain when he applied weight to the wrist with pushups.  In April 2004, he was referred to physical therapy where he was found to be able to sublux both wrists with ulnar and radial deviation, with pain only in the left wrist.  In December 2004, he was turning a wrench with his right hand and felt a “clunk” followed by pain in the wrist which resolved in less than a month.  The CI was on nearly continuous fitness restricting profiles beginning in April 2004 for “wrist pain” and an unrelated knee condition.  There was evidence of bilateral elbow hyperextension from the June 2004 orthopedic hand surgeon evaluation, but no documentation of pain or duty restrictions as a result.  There was no record of disability of either shoulder due to pain or subluxation, and while there was a single visit in October 2006 for complaints of bilateral ankle popping while walking, no evidence of instability was provided.  The CI did have right knee pain, however, there was no documentation of limiting instability in either knee.  

The panel considered its rating recommendation for the unfitting bilateral ligament laxity of the wrists at the time of separation.  At the MEB orthopedic evaluation, the CI reported a history of loose ligaments and dislocations of his wrists and knees.  Despite steroid injections, physical therapy and bracing for the wrists, he experienced minimal benefit.  Bilateral wrist examination revealed “good” grip strength, flexion, extension, supination and pronation; painful motion was not mentioned.  

During the 20 August 2007 rheumatology evaluation, requested by the Secretary of the Air Force Personnel Council (SAFPC) as part of an appeal to the Formal PEB proceedings, 3 months before separation, the CI reported joint laxity of the ankles, knees, wrists and shoulders, but no pain.  Physical examination showed normal wrists, elbows, shoulders, knees and ankles.  The provider did find ligamentous laxity at the elbows and from the thumbs to the wrists, but concluded that he did not meet the diagnostic criteria for hypermobility syndrome or other genetic connective tissue disorders.  

At the C&P examination, the CI reported daily bilateral wrist pain that prevented lifting, rotation, pushing or pulling without increasing pain.  Physical examination showed right and left wrist palmar flexion to 80 degrees (normal), dorsiflexion to 70 degrees (normal), ulnar deviation to 45 degrees (normal) and radial deviation to 20 degrees (normal).  Three repetitions caused an increase in pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and SAFPC determined the wrist ligament laxity to be an EPTS condition, coded 5299-5214 (wrist, ankylosis), citing a preponderance of medical evidence that the condition was developmental in origin and followed its expected natural course.  The VA did not service-connect the hypermobility of multiple joints based on the STR and C&P examinations, citing “hypermobility of the joints, in and of itself, is not considered to be a disability for which service connection can be granted under the law.”  Members adjudged that there was insufficient documentation to show subluxation of the joints caused an actual functional loss.  The panel also agreed there was no evidence of ankylosis or limitation of motion of either wrist to justify a rating under codes 5214 or 5215.  However, there was sufficient evidence of painful motion to support a 10% rating IAW with §4.59 for each wrist.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of each wrist favors their recommendation as additionally unfitting conditions for disability rating.  They are appropriately coded 5299-5215 and each meets the VASRD §4.71a criteria for a 10% rating.

BOARD FINDINGS:  In the matter of the right knee patellofemoral syndrome and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended wrist ligament laxity condition, the panel recommends that each wrist be found separately unfitting, and recommends a disability rating of 10% each, with both coded 5099-5215 IAW VASRD §4.71a.  In the matter of the contended ligament laxity of the shoulders, elbows, knees and ankles, the panel recommends no change from the PEB’s not unfitting, EPTS determination.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Patellofemoral Syndrome, Right Knee	5099-5003	10%	
Laxity of Ligaments, Right Wrist	5099-5215	10%	
Laxity of Ligaments, Left Wrist	5099-5215	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170215, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record