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

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02624.

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-2017-02624
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “right knee pain” and “back pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “Due to reentry code, rating should be higher also still suffering with chronic pain.”  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 - 20060519	VARD - 20061211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5257	10%	Back Pain	5257	10%	20061024	
Back Pain	5237	0%	Lumbosacral Strain	5237	20%	20061025	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right knee condition began in May 2005 after falling during hand-to-hand combat training.  The STR contained treatment entries where the CI reported knee pain and swelling, with buckling, locking or giving way.  Knee X-rays were normal.  Swelling was documented at the majority of visits, mainly above the patella but at times inferior to the patella.  A meniscal tear was suspected, but MRI on 30 September 2005 showed a “mildly discoid lateral meniscus” without a tear (discoid meniscus is an uncommon anatomical variant that usually is without symptoms but may become symptomatic).  In the year before separation, six of nine examinations in the STR noted positive testing for meniscal pathology.  Ligaments were unremarkable and there was no significant effusion.  Orthopedics did not recommend surgery.    

The 31 January 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of right knee pain, swelling, and stiffness, exacerbated by kneeling and stairs.  The CI also reported knee popping and grating with occasional locking or buckling.  Physical examination showed a normal gait and stance with tenderness and swelling of the upper half of the patella.  Range of motion (ROM) was not recorded.  Provocative testing showed a stable knee and no meniscal pathology.

The CI appealed the PEB’s findings and was referred for another orthopedic consult.  The Formal PEB’s (FPEB) referral to orthopedic surgery noted the CI had knee pain, swelling and limping since injury and the CI reported her knee had locked in flexion several times.  The FPEB referral noted a review of literature indicating an uncommon but possible discoid meniscus could be causing the CI’s persistent symptoms even without a tear, and perhaps a repeat MRI or arthroscopy was warranted.  At the orthopedic consultation on 2 May 2006, 2 months prior to separation, the CI reported recurrent problems with knee swelling and buckling.  The examiner noted the CI did not have “instability or locking symptoms.”  Physical examination showed right knee swelling that did not appear to be an effusion.  Right knee ROM lacked 10 degrees when compared to the left knee.  There was a “trace positive Lachman with a stable endpoint,” (suggesting anterior laxity with the anterior cruciate ligament [ACL] intact) and other examination maneuvers to test stability were negative.  There was no evidence of meniscal pathology.  The orthopedic surgeon reviewed the MRI and indicated there appeared to be a partial right ACL tear and no evidence of a meniscal tear or other pathology.  No surgery was recommended.  

During the 21 October 2006 VA Compensation and Pension (C&P) general medical examination, 3 months after separation, the examiner noted an antalgic gait.  Three days later, at the C&P joints examination, the CI reported right knee pain, swelling, loss of ROM, instability, popping, clicking, and giving way which precluded squatting, kneeling, or walking long distances.  Physical examination showed a moderately antalgic gait.  There was tenderness and a knee effusion graded 2+/3+.  There was positive testing for anterior instability and mild medial collateral ligament laxity graded 1+/3+ (mild).  Testing for meniscal pathology was positive.  There was normal patellar tracking.  Right knee ROM testing showed extension of 0 degrees (normal) and flexion of 110 degrees (normal 140) with painful motion.  The 25 October 2006 C&P spine examination noted an antalgic gait due to the right knee.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5257 (knee impairment due to recurrent subluxation or lateral instability).  The VA also rated the right knee condition 10%, coded 5257, based on the C&P examination, citing slight lateral instability.  

The MEB NARSUM examination noted a normal gait and no instability or meniscal pathology.  However, the panel considered the CI consistently reported, including to the FPEB, experiencing locking or buckling of the right knee throughout the course of her treatment.  An antalgic gait was noted at visits in the STR throughout the course of treatment as well, including the visit for the FPEB referral, and at all three C&P examinations.  Knee swelling was noted at the majority of examinations in the STR including the NARSUM, the orthopedic consult and C&P examination.  The MRI noted a variant meniscus that could become symptomatic.  Multiple examinations in the STR before and after the MRI noted positive testing for meniscal pathology.  The orthopedic consult did not find evidence of meniscal pathology but indicated there was evidence of a partial ACL tear on the MRI.  He indicated that the CI had no symptoms of instability or locking, which contradicted the CI’s reported symptoms at examinations over the prior 10 months.  The panel considered that by the time of the NARSUM and orthopedic consult, the knee may have improved due to time and physical therapy, however, at the C&P examination, performed by an orthopedic surgeon, the physical examination showed significant knee swelling and positive testing for instability and meniscal pathology.  

The panel also noted the medical evidence in record did not reach a definitive diagnosis of the CI’s knee condition.  Therefore, the panel discussed whether a rating under 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) should be considered in this case, as opposed to rating based on 5257 knee impairment criteria.  However, since the PEB adjudicated the “knee pain associated with partial right ACL tear,” the panel agreed the 5257 code should be retained for its rating recommendation and then deliberated between a 10% rating and a 20% rating.  The panel majority agreed there was conflicting evidence in the record regarding the degree of functional instability, but coded analogously to 5257, a 20% rating more nearly approximated the CI’s disability due to the knee condition for moderate recurrent subluxation or lateral instability, than a 10% rating for slight recurrent subluxation or lateral instability, IAW VASRD §4.3 (reasonable doubt) and §4.7 (higher of two evaluations).  

The panel also considered if there was evidence to support dual coding of the knee for instability and knee pain.  However, in this case the adjudication was for knee pain and the panel consensus was that the knee pain could be due to instability or another cause, but that two ratings could not be assigned for the same symptoms under two different diagnoses IAW VASRD §4.14 (avoidance of pyramiding).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the right knee condition, coded 5299-5257.  

Back Pain.  According to the STR and MEB NARSUM, the CI was first seen for back pain on 25 October 2005.  The CI reported the pain was present ever since her knee injury.  Thoracic and lumbar spine X-rays were normal.  The chiropractor, on 19 December 2005, 7 months prior to separation, noted tenderness and full ROM with painful motion.  Radicular signs were negative and the neurological examination was normal.  Visits for chiropractic treatment between December 2005 and March 2006 noted only tenderness of the lumbar and/or thoracic spine.  Thoracic muscle spasm was noted at one visit in April 2006.  The 31 January 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of low back pain which radiated to the right hip.  Physical examination showed tenderness, a normal gait, and full painless ROM.  

At the 25 October 2006 C&P spine examination, 4 months after separation, the CI complained of intermittent back pain without significant lower extremity radicular symptoms.  She denied any episodes of incapacitating back pain over the last year.  Physical examination showed a moderate antalgic gait, but this was in reference to the right knee and not the back.  There was mild muscle spasm and tenderness, but spinal contours were normal.  Thoracolumbar ROM testing showed forward flexion of 50 degrees (normal 90) and combined thoracolumbar ROM of 200 degrees (normal 240) with pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain).  The VA rated the back condition 20%, coded 5237, based on the C&P examination, citing limitation of motion.  There was evidence of tenderness at the NARSUM and C&P examinations.  Although ROM at the C&P examination documented flexion of 50 degrees, which supports a 20% rating, all references to back ROM prior to separation indicated full ROM.  The post-separation C&P examination noted mild lumbar muscle spasm which may have caused acute limitation of motion, but there was no evidence in the record that motion was ever limited to this degree prior to the C&P examination and there is likewise no evidence that muscle spasm was a frequent occurrence.  The panel agreed the CI’s back disability was more nearly approximated by the 10% rating criteria than the 20% rating IAW VASRD §4.7.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the right knee condition, the panel majority recommends a disability rating of 20%, coded 5299-5257 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the back condition, the panel recommends a disability rating of 10% coded 5237 IAW VASRD §4.71a.  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	
Right Knee Pain	5299-5257	20%	
Back Pain	5237	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170320, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record