RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03885
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20081201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E6, Health Service Management Craftsman, medically separated for “right knee pain” with a disability rating of 10%.   

CI CONTENTION:  Review of his knee, back and headache condition was requested.  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 - 20081016	VARD - 20090608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain 	5099-5014	10%	Right Knee Chondromalacia Patella with Degenerative Changes	5014	10%	20090312	
Low Back Pain	Cat II	Lumbosacral Strain with Degenerative Changes	5237	20%	20090312	
Migraines	Cat II	Migraines	8100	0%	20090312	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

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 2005 with no specific injury or trauma reported.  Treatment was initially conservative (rest, non-steroidal anti-inflammatories and physical therapy (PT).  The CI underwent a right knee arthroscopy in October 2006 with debridement of degenerative changes of the joint and meniscus, without resolution of her symptoms.  She was advised she had arthritis.  Knee MRI in September 2007 showed moderate chondromalacia patella and focal cartilaginous defect in the posterior tibial plateau with pre-patellar bursitis.  The cruciate and collateral ligaments were intact and the meniscus was normal in appearance without evidence of a tear. At the orthopedic physical examination on 20 May 2008 there was full range of motion (ROM) and no evidence of instability or meniscal pathology. The 10 July 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of continued pain with occasional swelling in the anterior knee.  Physical examination showed full ROM and normal muscle strength.  There was no evidence of laxity, instability, or meniscal pathology.  There was mild patellar apprehension with crepitus through ROM.  

At the 12 March 2009 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported daily right knee pain with periodic swelling and “giving out.”  She reported she had a walking cane and a knee brace but she did not use an assistive device at the examination.  Physical examination showed gait was antalgic.  There was no swelling or deformity noted.  Flexion was 95 degrees (normal 140) with pain at the end of flexion and extension was 0 degrees (normal).  Movement was slow and guarded due to pain during the entire range of flexion.  An MRI showed moderate chondromalacia patella, prepatellar bursa fluid and cartilaginous defect.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee, condition 10%, analogously coded 5099-5014 (osteomalacia), citing full ROM and strength.  The VA also rated the right knee chondromalacia patella with degenerative changes 10%, coded 5014 (osteomalacia) based on the C&P examination, citing painful or limited motion to 95 degrees.  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).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under that code.  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 higher than 10% supported under any applicable VASRD §4.71a 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 pain condition.  

Contended PEB Conditions:  Low Back Pain and Migraines.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. The profile was an L4T profile and the medical examination for separation from active duty on 11 September 2007 indicated the CI’s profile was updated and was a “continuation of 4T profile for low back and knee issues.”  The 20 August 2008 commander’s statement implicated “medical conditions,” without specific mention of conditions.  At the orthopedic examination on 20 May 2008 the CI was recommended as not fit for duty due to her lumbar spine degenerative disc disease (DDD).  The MEB NARSUM referred the CI to the PEB for intervertebral disc degeneration and recommended that the CI continue care for chronic back pain.  The panel agreed there was a preponderance of evidence to recommend the low back condition as additionally unfitting at separation and eligible for disability rating.  

According to the STR and MEB NARSUM, the CI reported the low back pain began the year prior to the MEB review.  No specific mechanism of injury was reported.  An MRI of the back in May 2007 showed DDD with disc bulging and ligament hypertrophy at L4-5 causing mild narrowing of the lateral recesses and neuroforamina bilaterally (area through which the spinal nerves exit). The orthopedic examination on 20 May 2008, 6 months prior to separation, noted that right knee pain and low back pain with right leg pain and muscle spasms caused the CI to be unable to perform her duties or physical fitness training.  The examiner noted the CI had an antalgic gait and had difficulty putting her shoes on.  Right lower extremity weakness was observed and straight leg raise (SLR) testing to elicit radicular symptoms was positive on the right.  The 10 July 2008 MEB NARSUM examination physical examination showed normal alignment of the back.  There was full ROM with normal muscle strength, and SLR was negative.  There was mild to moderate paravertebral spasm from L2 through S1, right greater than left.  At a VA outpatient visit to establish care on 14 November 2008, one month prior to separation, physical examination showed a limp favoring the right knee.  There was pain with spine flexion at 45 degrees (normal 90) and with side bending and SLR was negative.  

At the 12 March 2009 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported low back pain with flare-ups due to bending or at times just upon awakening and flare-ups lasted 1 to 2 weeks.  She took anti-inflammatory medication as needed.  She denied any periods of incapacitation requiring bed rest in the last year.  The CI was not using an assistive device for ambulation at the examination.  Her gait was antalgic.  There were no abnormal spinal curvatures or muscle spasm.  Lumbar spine ROM was flexion of 55 degrees and combined ROM of 190 degrees (normal 240).  The examiner noted that all movements of the spine were performed slowly with guarding and with exacerbation of pain on all movements.  At the VA outpatient neurological examination on 31 March 2009, the CI reported low back pain that occasionally radiated down the right lower extremity with numbness and tingling of the right foot.  She reported a pain level of 3/10 that day.  Gait was normal.  Strength and reflexes were normal and non-radicular sensory abnormalities were noted.  The CI was found to be B-12 deficient (causes sensory changes).  

The panel noted that full ROM of the back was documented at the MEB NARSUM examination supporting a 10% rating, while the VA examinations shortly after separation showed flexion supportive of a 20% rating.  The VA evidence which includes a visit 2 weeks prior to separation and the C&P examination and PT visit within 6 months of separation support a 20% rating based on limitation of thoracolumbar ROM.  Multiple examinations in record before and after separation documented frequent muscle spasms which were severe enough to preclude testing (including ROM); an antalgic gait was documented at the VA PT examination.  The panel agreed the CI’s disability due to the back was more nearly approximated by the 20% rating criteria than 10%, based on the total evidence in record.  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 20% for the low back condition, coded 5243.
  
The migraine condition was not profiled or implicated in the commander’s statement and did not fail retention standards.  There was no performance-based evidence from the record that the migraine condition significantly interfered with satisfactory duty performance at separation.    

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the contended low back condition, the panel recommends an unfitting determination and recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71.  In the matter of the contended migraine condition, the panel agrees it cannot recommend it for additional disability rating.  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	5099-5014	10%	
Low Back Pain	5243	20%	
COMBINED	30%	

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-2017-03885.

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 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.