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AF | PDBR | CY2013 | PD-2013-02210
Original file (PD-2013-02210.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX      CASE: PD -20 13 - 0 2210
BRANCH OF SERVICE: AIR FORCE      BOARD DATE: 2014 1007
Separation Date: 20060828


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (2W1/Aircraft Armament Systems Craftsman) medically separated for bilateral knee pain. The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was issued a permanent L4 profile and referred for a Medical Evaluation Board (MEB). The bilateral knee pain condition, characterized as “medically unacceptable” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB adjudicated “bilateral knee pain” as unfitting, rated 20% with likely application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION : “Rheumatoid Arthritis”


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 bilateral knee pain condition is addressed below; no additional conditions are 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.


RATING COMPARISON :

Service IPEB – Dated 20060628
 VA - (01 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Knee Pain 5099-5002 20% Rheumatoid Arthritis 5002 20% 20061019
No Other Items in Scope
Combined: 20%
 Combined: 20%
Derived from VA Rating Decision (VARD) dated 20070131 (most proximate to date of separation [DOS])


ANALYSIS SUMMARY : The PEB rated the b ilateral k nee p ain condition under the single analogous code of 5099-500 2 r heumatoid a rthritis. This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation. The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as unfitting in and of itself, with the caveat that the final recommendation may not produce a lower combined rating as that of the PEB.
Bilateral Knee Pain Condition . The CI initially developed left knee pain after a f a ll . A left knee X -ray was normal . A magnetic resonance imaging ( MRI ) of the left knee showed a large suprapatellar effusion and a thickened medial plica. The CI continued with left knee pain and was seen by physical therapy ( PT ) for an evaluation. The o rth o pedist noted that the CI had bilateral knee joint pain with the left worse than the right and worse in the morning, joint stiffness, swelling, a grating sensation and increased with bending. The left knee anteromedial aspect was tender on palpation, the superior patella pole was tender on palpation and pain w a s elic i ted with flexion. Rheumatolog y evaluation 4 months later documented swelling in both knees; worse pain in morning associated with an hour of morning stiffness and increased pain with over activity and periods of non-activity. There were physical exam findings of bilateral tenderness over the bursa. The r heumatologist opined that there was no diagnostic evidence to support a diagnosis of systemic lupus, rheumatoid arthritis or other systemic inflammatory disease ; but did note that the CI had a family history for autoimmune disease. Thr ee months after that evaluation , the CI was seen in the emergency room for an exacerbation of bilateral knee swelling and pain had been treated with a non-steroidal anti-inflammatory drug (NSAID) and a narcotic for pain. Laboratory testing showed a normal C-reactive protein and a normal sedimentation rate. The CI was sent to PT for bilateral knee pain. A bilateral knee MRI showed moderate effusions with thickened synovium, left greater than right. In January 2006, a rheumatoid factor laboratory test was positive; this had been negative in the past. The r heumatologist noted a failed response to PT, NSAIDS and documented fatigue 7/10, difficulty perform ing activities of daily living and work interference due to knee pain. The examiner opined that the CI had asymmetric arthritis involving large and small joints and now had a positive rheumatoid factor. He further opined that the differential diagnosis included rheumatoid arthritis and she was started on E tanercept (an anti-rheumatologic disease modifying drug) and a steroid taper. The ME B narrative summary exam approximately 4.5 months prior to separation documented recurrent morning joint stiffness up to an hour in duration without any recent episodes of conjunctivitis, fevers, chills, rash or rheumatoid nodules. The physical exam findings were tenderness to palpation of both knee joints. The CI was given an L4 Profile . The c ommander’s s tatement indicated that the CI was not capable of deploying due to her 4T p rofile and her condition interfered with her MO S duties. T he VA Compensation and Pension exam approximately 1.5 months after separation documented that the CI reported stiffness and weekly pain that lasted all day , in both knees . There was weakness bilaterally with stooping only. She further reported that standing longer than 3 to 4 hours per day precipitated pain. The physical exam findings were tight joint capsules bilaterally and range - of - motion for the right knee flexion 135 degrees and extension 5 degrees and left knee flexion 130 degrees and extension 5 degrees with normal strength bilaterally.

The Board directs attenti on to its rating recommendation based on the above evidence . The PEB coded the b ilateral k nee p ain condition as 5099 analogous to 5002 a rthritis rheumatoid (atrophic) as an active process and rated at 20% - o ne or two exacerbations a year in a well-established diagnosis . The VA coded the r heumatoid a rthritis condition as 5002 and also rated it 20%. All documents proximate to separation indicated that the CI experienced bilateral knee pain which was attributed to rheumatoid arthritis. The CI had an exacerbation in February 2006 and was treated with a prednisone taper and started on Etanercept monthly injections. The CI was continued on the monthly E tanercept injections and there was no documentation of any exacerbations in either knee. The Board notes that rating under code 5002 accounts for disability in both knees due to an active rheumatoid process. Board members agree that there were insufficient grounds for recommending separate right and left knee disability ratings at the time of separation . Even if both knees are conceded as separately unfitting, the data would support a 10% evaluation for each knee under code 5003 and confer no benefit to the CI. 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 b ilateral k nee p ain 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 b ilateral k nee p ain 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 20 131105 , w/atchs
Exhib it 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-2013-02210.

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

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