RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01237
BRANCH OF SERVICE:  aIR FORCE 	SEPARATION DATE:  20081107

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Explosive Ordnance Disposal Craftsman, medically separated for “chronic left knee pain, post-traumatic osteoarthritis and decreased range of motion” with a disability rating of 10%.

CI CONTENTION:  “I received a disability severance pay upon leaving the military in the sum of $50,000.  I am currently 100% disabled and I am paying back the severance pay.  It’s my feeling since my injury did not let me . . . [incomplete sentence].  I feel if I have to return my severance pay of $58,000 that I should receive my retirement as I was unable to complete my military career due to my injury.”  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 - 20080918	VARD - 20090324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lt Knee Pain, Post-Traumatic Osteoarthritis	5099-5003	10%	Lt Knee Lateral Patella Dislocation Status Post Lt Knee Arthroscopy, DJD of Lt Knee, No Functional Impairment	5010-5260	10%	20090303	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain, Post-Traumatic Osteoarthritis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic knee pain condition began in February 2007 after running.  In 2001 the CI dislocated his patella and underwent left knee arthroscopy with loose body removal, the results of which did not limit the performance of his military duties, although he experienced pain in the knee.  

At a 27 February 2007 primary care clinic appointment, the CI reported increased pain in the knee, especially with running and he experienced popping with twisting motions.  Examination showed no tenderness of the knee, instability or muscle weakness.  Knee flexion and extension were normal with no pain elicited by motion.  X-rays of the left knee on 27 February 2007 demonstrated degenerative changes of the patellofemoral compartment, most prominent medially.  An MRI on 2 March 2007 showed mild chondromalacia (cartilage degeneration) present within all three compartments in a diffuse fashion.  There was no focal osteochondral defect or loose body identified.  A small joint effusion was present.  There were no meniscal tears, but there was some degeneration of the posterior horns of both menisci.  The cruciate and collateral ligaments were intact.  

At a 1 May 2007 orthopedic visit, the CI complained of left knee pain with some popping.  Examination revealed no effusion or erythema.  He had significant crepitus (grinding sensation) under the patellofemoral joint and pain along the lateral aspect of the patella facet and mild pain with patellofemoral compression.  The left knee range of motion (ROM) was 0-130 degrees (normal 140).  The knee was stable to varus and valgus stress testing with mild atrophy and no joint line tenderness.  The CI was diagnosed with left knee patellofemoral arthritis status post patella dislocation.  

Since the previous left patella dislocation surgery, the CI developed difficultly with the undersurface of his patella with popping, locking and occasional difficulty with extension and flexion.  On 17 May 2007 the CI underwent left knee arthroscopy with chondroplasty of the medial femoral condyle and the patella.  Two weeks postoperatively, the CI had some burning pain, but returned to weight-bearing as tolerated.  ROM was 0-100 degrees.  

At the 7 June 2007 orthopedic clinic appointment, the CI complained of significant left knee pain.  He reported chills, fever and increasing pain to the point where he had difficulty weight bearing that morning.  The examiner noted the possibility of infection.  The CI then underwent irrigation, debridement, and culture as well as intravenous antibiotics.  At the 12 June 2007 orthopedic follow-up appointment, the CI reported no fever or chills, and his pain was significantly improved.  Examination of the left knee revealed healing surgical incisions without erythema or drainage.  The left knee ROM was 0 to 130 degrees with no joint line tenderness and no pain with axial load.  Cultures taken at the time of irrigation and debridement revealed no evidence of bacterial growth.  The examination at the 14 June 2007 physical therapy appointment revealed an antalgic gait on the left.  Surgical incisions were well healed with no signs of infection.  The left knee ROM was -30 degrees extension (normal 0) and flexion of 120 degrees.  There was 3+/5 quadriceps strength and 4/5 hamstring strength.  At the 12 July 2007 physical therapy appointment, examination revealed full active ROM for the left knee.  Quadriceps strength was 4+/5 and hamstring strength was graded at 5/5.  Gait was normalized with equal swing and stance phases.  Patellar mobility was well reestablished.  

On 14 January 2008 during a primary care visit, the CI complained of daily pain in his left knee with squatting, running or any repetitive lower extremity activity.  On examination there was mild left quadriceps atrophy and the ROM was within normal limits. There was no joint line or patellar tenderness, no laxity or evidence of a meniscal tear, and negative patellar apprehension, but he had difficulty completing the patellar grind test.  

At the 25 January 2008 orthopedic clinic appointment the CI reported significant pain with activities.  He was no longer able to perform the duties of his job and had significant difficulty running with any type of weight on his shoulders.  Physical examination of the left knee revealed no significant erythema or effusion.  His incisions were well healed and his ROM was 0 to 110 degrees.  He had significant tenderness over his medial patella facet and medial femoral condyle.  The knee was stable to varus and valgus stress testing.  The examiner stated the CI was no longer able to perform his duties; nevertheless, possible interventions including patellofemoral arthroplasty versus an osteochondral allograft were to be considered.  

The 27 July 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of significant left knee pain.  On examination the left knee ROM was 0-110 degrees with crepitus over the medial aspect of his knee.  There was no significant effusion, erythema, or rash to the knee.  The incisions were well healed, but showed significant point tenderness over his medial patellar facet and the medial femoral condyle.  The knee demonstrated no laxity, instability, or evidence of a meniscal tear.  X-rays of his left knee, including weight bearing and notch views, showed evidence of moderate osteoarthritis of the medial compartment as well as significant osteoarthritis of the patellofemoral compartment on the medial side.  The CI also had osteophytes on the superior aspects of his patella.  The final diagnosis was post traumatic osteoarthritis.  

At the 3 March 2009 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported symptoms of pain, stiffness, weakness, instability, and occasional rare swelling.  He also had problems with extension and walking up and down stairs and hills.  The pain intensity was reported as 2/10, occurred every other day, and lasted for 1-2 hours.  Flare-ups occurred about once every 2 weeks for 2-3 hours.  The CI’s posture was erect with a normal gait.  No assistive device was used.  Physical examination showed left knee ROM of 0-105 degrees for flexion and normal extension.  There was no laxity, instability, or evidence of a meniscal tear, and a grind test was negative.  X-rays studies showed mild patellar chondromalacia with no evidence of fracture or joint effusion.  The examiner’s diagnoses were left knee lateral patella dislocation status post left knee arthroscopy, left knee degenerative joint disease (DJD) with no functional impairment; and a resolved postoperative intra-articular infection with no objective residual finding and no functional impairment.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5099-5003 (degenerative arthritis).  The VA rated the left knee condition 10%, coded 5260 (leg, limitation of flexion), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  

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).  There was no X-ray evidence showing involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations to warrant a 20% rating.  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 proximate to separation causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those respective codes  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).  Therefore, there was no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 pain condition.  

BOARD FINDINGS:  In the matter of the chronic left knee pain 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 20170224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2017-01237.

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