RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-01158
BRANCH OF SERVICE:  AIR FORCE 	BOARD DATE:  20140918
SEPARATION DATE:  20070409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (2A752/Nondestructive Inspection Journeyman) medically separated for a right knee condition.  The right knee condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS) or satisfy physical fitness standards.  She was issued an L4 profile and referred for a Medical Evaluation Board (MEB).  The right knee condition, characterized as “recurrent right knee pain of an uncertain etiology,” was forwarded by the MEB to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic right knee pain due to patellofemoral syndrome” as unfitting, rated 10%, referencing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI stated, “I am currently at 60% and that is also being appealed at this time.  Rating has increased 50% since medical discharge and is in appeal for PTSD re-rating.”

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right knee condition is addressed below; however, the PTSD condition was not identified either the MEB or PEB and thus is not within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records. 

The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veteran Affairs, operating under a different set of laws.   The Board considers VA evidence proximate to separation in arriving at its recommendations and DoDI 6040.44 defines a 12 months interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

RATING COMPARISON:  

Service IPEB – Dated 20070201 | VA - (13 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Right Knee Pain Due to Patellofemoral Syndrome | 5099-5003 | 10% | Patellofemoral Pain Syndrome, Right Knee | 5260 | 10%* | 20080509
Other x 1 (Not is Scope) | Other x 4 | 20080509
Rating:  10% | Rating:  10%
Derived from VA Rating Decision (VARD) dated 20080620 (most proximate to date of separation)   
*Rating was increased to 30% effective 20111013

ANALYSIS SUMMARY:  

Right Knee Pain due to Patellofemoral Syndrome.  The CI presented in January 2004 for right knee pain after a twisting injury.  Persistent pain was evaluated with a magnetic resonance imaging (MRI) study in November 2004, which showed medial meniscal degenerative changes but no definite tears.  At arthroscopy in January 2005, a medial plica (redundant tissue) was excised, but there was no other significant pathology.  The CI experienced a slow recovery and was re-evaluated by follow-up MRI’s and orthopedic specialty examinations.  Despite ongoing pain that was refractory to physical therapy and [steroid] injections, no surgical indication was found.

An orthopedist evaluation dated 9 August 2006 (8 months prior to separation) noted that evaluations by three different orthopedists could not identify a clear cause of the CI’s pain.  Examination showed diffuse tenderness, but no swelling or ligament laxity.  Primary care notes in August thru September 2006, documented complaints of right knee pain and examination findings of tenderness without ligament laxity.

At the narrative summary (NARSUM) examination on 28 November 2006 (approximately 5 months prior to separation), the CI complained of right knee pain that was diffuse and 8/10 in severity with occasional periods of 10/10 pain.  She reported occasional popping, locking and instability.  Examination revealed a mild effusion (swelling) of the right knee with painful motion.  Tests for ligament instability were negative.  Tenderness was not present.  Range-of-motion (ROM) measurements were not reported.  The examiner noted that recent orthopedic evaluations did not reveal evidence of internal knee derangement or other treatable disorder.

At the VA Compensation and Pension (C&P) exam on 9 May 2008 (13 months after separation), the CI reported that she underwent another right knee arthroscopy in September 2007 (5 months after separation).  Although symptoms improved after the surgery, she continued to experience mild to moderate pain on a daily basis and occasional swelling at the end of the day.  She denied instability or locking.  Examination showed an antalgic (limping) gait due to knee pain.  All ligaments were stable.  Repetitive motion did not result in additional limitation.  The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

Right Knee ROM
(Degrees)

ORTHO ~ 8 Mos. Pre-Sep

VA C&P ~ 13 Mos. Post-Sep

Flexion (140 Normal) | 110 | 125
Extension (0 Normal) | 0 | -5 from full extension
Comment | +diffuse tenderness | +tenderness, painful motion
§4.71a Rating | 10%* | 10%*
		*Conceding §4.40 (functional loss) or §4.59 (painful motion)
The Board directed attention to its rating recommendation based on the above evidence.  Although the service exam reported non-compensable limitation of motion, the PEB’s 10% determination under an analogous 5003 code (degenerative arthritis) was appropriate considering there was sufficient evidence of pain with use §4.40 (functional loss) and §4.59 (painful motion).  Because the VA C&P exam was greater than a year post-separation and followed a post-separation surgical intervention, the Board assigned it little probative value relevant to the time of separation.  The Board considered other coding pathways to a rating higher than 10%.  There was no evidence of recurrent subluxation or lateral instability, no history of dislocated semilunar cartilage and no history of removal of semilunar cartilage to warrant ratings under codes 5257 (knee, other impairment of), 5258 (dislocated semilunar cartilage) or 5259 (cartilage, semilunar, removal of, symptomatic).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic right knee pain condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chronic right knee pain due to patellofemoral syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-01158

	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,

XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD-2014-01158