RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03355
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Missile and Space Systems Maintenance Journeyman, medically separated for “right knee, patellofemoral arthritis” 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 - 20051205	VARD - 20061221	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee, Patellofemoral Arthritis	5099-5003	10%	Residuals, Injury to Right Knee with Patellofemoral Syndrome 	5010-5257	10%	20060926	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Knee Patellofemoral Arthritis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent right knee arthroscopic surgery with chondroplasty of the retropatellar cartilage and a lateral retinacular release in July 2004.  At an orthopedic examination on 22 March 2005, the CI reported persistent anterior knee pain with associated mild, intermittent swelling.  He also experienced numbness and tingling in the knee and stated that “something in there [did] not feel right.”  The pain also occurred during cold weather and an anti-inflammatory medication provided only some relief.  Although he was treated in physical therapy “off and on” for a 6-month period, there was no focus on the patellofemoral mechanism.    Physical examination showed “full, unobstructed range of motion” (ROM), and no effusion, instability to straight line and rotational testing, or joint line tenderness.  At a follow-up orthopedic visit on 22 June 2005, 7 months prior to separation, the CI complained of right knee swelling exacerbated by climbing, kneeling, jumping and running.  Physical examination showed full knee ROM and no significant effusion or instability, but some patellofemoral apprehension and discomfort with patellar motion.   On 19 July 2005, orthopedic examination noted well-healed portals, and no effusion, instability or patellofemoral apprehension.  However, there was “significant lateral joint tenderness,” and the examiner could not “discern a McMurray on that side.”  A week later at a primary care visit, the provider documented flexion decreased to 110 degrees with no further elaboration of physical findings.  

At the 22 August 2005 primary care examination, the CI complained of flare-ups after repetitive bending and kneeling, and reported that non-steroidal anti-inflammatory medication provided some relief.  He also described significant knee swelling during a long cross country trip by car.  Physical examination showed distinct retro-patellar tenderness medially and inferiorly, and positive patellar grind and lateral patellar tracking along with obvious vastus medialis obliquus dysfunction and atrophy medially.  Drawer, Lachman, McMurray and varus/valgus stress testing were are all negative as was a pivot shift test; there was no effusion.  The provider noted that a July 2005 MRI that showed no evidence of meniscal tear, but revealed chondromalacia patella in the area of the previously described retro-patellar defect.  Additionally, knee X-rays in August 2005 showed considerable narrowing of the patellofemoral joint. 

The 24 September 2005 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of swelling with his knee pain, especially with activity. The examiner deferred to the 22 August 2005 primary care findings and did not examine the CI.   On 11 August 2006, 7 months after separation, the CI underwent a second right knee surgery which included: diagnostic arthroscopy, lateral retinacular release, synovectomy with arthrofibrosis resection of the patellar tendon, and laser chondroplasty to “that of the patella, superolateral facet.”

At the 26 September 2006 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI complained of stiffness in the morning and after being on his feet for a long time, but reported no locking that since the August surgery.   Physical examination showed a normal gait and posture, and ROM measurements revealed extension to 10 degrees and flexion to 130 degrees, with pain beginning at 85 degrees; with repetitive movement, flexion was to 120 degrees.  There were no signs of meniscal tears or joint laxity, and varus and valgus movements caused minimal discomfort.  The examiner noted crepitus behind the patella and that the CI was only able to partially squat with a popping noise in the knee joint heard when doing so.  Knee X-rays were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded as 5003 (degenerative arthritis).  The VA also rated the right knee condition 10%, but dual coded 5010-5257 (traumatic arthritis-other impairment of knee:  recurrent subluxation or lateral instability), based on the C&P examination, citing evidence of recurrent, slight knee subluxation or lateral instability.  Panel members agreed that while there was no limitation of flexion or extension (5260 or 5261) for a compensable rating, there was evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45). Code 5259 (cartilage, semilunar, removal of, symptomatic) was also applicable in this case, but the maximum 10% rating under that code 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).  There was therefore no VASRD §4.71a rating higher 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 right knee 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.  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:

SAF/MRB

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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-2017-03355.

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.

						

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