RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01885
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “right knee pain status post repair of anterior cruciate ligament” and “right ankle pain, status post removal of bone spur,” rated 10% each, with a combined disability rating of 20%.  

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 - 20080220	VARD - 20081229	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain, S/P Repair of Torn ACL	5099-5003	10%	Right Knee Impairment S/P ACL Repair	5257-5024	10%	20081110	
Right Ankle Pain, S/P Removal of Bone Spur	5273	10%	Chronic Right Ankle Sprain, S/P Bone Spur Removal, with Right Lateral Malleolar Pain	5024	10%	20081110	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Knee Pain, Status Post (S/P) Repair of Torn Anterior Cruciate Ligament (ACL).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right knee condition began in the latter part of 2005 after twisting his knee while playing basketball.  On 17 January 2006 the CI underwent right ACL reconstruction with a hamstring (semitendinosus tendon) autograft and posterior tibial tendon allograft.  The CI underwent postoperative physical therapy and by April 2006 was full weight bearing and doing well.  

On 30 March 2007 the CI reported a 1 month history of right knee pain.  Examination revealed no swelling, erythema, or tenderness of the knee.  A valgus stress test (for laxity) was negative with subjective discomfort.  There was a negative patella grind test, a negative McMurray’s test (to determine a meniscal tear), and negative anterior and posterior drawer tests.  Physical therapy range of motion (ROM) measurements of the right knee on 21 November 2007 were flexion 120 degrees (normal 140) and extension 0 degrees (normal 0).  The CI did not appear to be in discomfort during testing.  An MRI of the right knee on 11 December 2007 showed the ACL repair appeared intact with grade II myxoid degeneration of the posterior horn of the medial meniscus without a definite tear, and an abnormal signal in the posterior horn of the lateral meniscus that was believed to be a complex predominantly vertical tear in the posterior horn that was present in 2005.  

The 13 December 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of chronic right knee and ankle pain.  Physical examination showed no effusion, erythema, or warmth.  The patella was not shifted laterally or medially and there was no crepitus (grinding sensation) or apprehension.  No tenderness was present at the lateral patellar retinaculum or at the joint line.  The knee ROM was 0-120 degrees (normal 0-140) and there was no pain on motion.  

At the 10 November 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported dull, aching pain across the anterior aspect of the right knee which came and went with no exacerbating factors.  The knee occasionally locked up and buckled. Physical examination showed a normal gait.  ROM of the right knee was 0-130 degrees with end of range pain, but was not limited by repetition.  There was no laxity, tenderness, or evidence of a meniscal tear of the right knee, but there was mild crepitus.  An X-ray of the right knee revealed a surgical repair of the right ACL, but was otherwise within normal limits.  

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%, dual coded 5257-5024 (knee, other impairment of-tenosynovitis), based on the C&P examination, citing painful and limited motion of a major joint.  

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 subjective painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40, and 4.45).  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 causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259), to support a rating under the respective codes.  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 higher rating option than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all 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 right knee condition.  

Right Ankle Pain S/P Removal of Bone Spur.  According to the STR and MEB NARSUM, the CI’s right ankle condition began while deployed in 2005 during a cross-loading exercise when he stepped on some rocks and had an inversion injury.  Physical therapy was instituted in July 2006 to ameliorate the ankle pain due to an ATFL (anterior talofibular ligament) injury, and was continued through 12 September 2006.  X-rays dated 14 September 2006 demonstrated no evidence of fracture or subluxation, with the talar dome and mortise intact and no soft tissue swelling or ankle joint effusion.  

The CI underwent osteophyte excision of the right ankle on 29 December 2006.  He was casted for the first 2 weeks and used a fracture boot for 6 weeks thereafter, and also underwent postoperative physical therapy.  ROM of the right ankle on 27 February 2007 was 0-35 degrees, limited secondary to pain.  There was no edema or effusion and muscle strength was normal.  The CI reinjured and twisted his ankle during training on 28 March 2007.  Examination on 30 March 2007 revealed tenderness of the right ankle on the lateral aspect.  There was no swelling or erythema and the ROM was limited by pain.  X-rays of the right ankle dated 30 March 2007 revealed no osseous, articular, or soft tissue abnormalities.  On 10 June 2007 the CI reported ankle swelling.  On examination there was tenderness of the lateral aspect of the right ankle, but no swelling or erythema.  An MRI of the right ankle dated 11 December 2007 revealed the ATFL did not appear to be normal with a thin portion of the ligament intact, and scar tissue.  There was also a moderate non-specific subtalar joint effusion.  

The MEB NARSUM examination noted complaints of chronic right knee and ankle pain.  Physical examination of the right ankle showed no swelling, erythema, warmth, induration, or deformity.  There was no tenderness anterior, medially, or laterally or at the Achilles tendon insertion.  ROM measurements were dorsiflexion 10 degrees (normal 20) and plantar flexion 60 degrees (normal 45) without pain.  There was no laxity or subluxation and there was no evidence of an Achilles tendon rupture.  The ankle was not tender on ambulation and there was no swelling or tenderness of the right foot.  

At the C&P examination the CI reported constant, dull, aching pain around the right lateral malleolus with occasional swelling and some instability that locked up and tended to give way quite often.  Physical examination showed a normal gait and the CI could dorsiflex 20 degrees and plantar flex 45 degrees without pain.  Neither motion was limited by repetition.  There was no tenderness or instability of the ankle.  A well-healed scar was present just lateral to the medial malleolus of the right ankle.  An X-ray of the right ankle revealed mild inflammation anterior to the distal tibia.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, coded 5273 (os calcis or astragalus, malunion of-moderate deformity).  The VA also rated the right ankle condition 10%, coded 5024 (tenosynovitis), based on the C&P examination, citing painful motion of a major joint.

Panel members noted that the PEB used code 5273, which presumably was related to the osteophyte excision procedure.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  Because there was no ankylosis, nonunion, or malunion other than that referred to by the PEB by use of code 5273, VASRD §4.71a offers no applicable joint code which would yield a rating higher than the 10% adjudicated by the PEB.  The panel also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7); however all panel members agreed that the impairment did not more nearly approximate moderately severe to support a higher rating.  After due deliberation, considering all 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 ankle condition.  

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right ankle 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 20170328, 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-2017-01885.

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