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AF | PDBR | CY2013 | PD-2013-02546
Original file (PD-2013-02546.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-02546
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20140814
SEPARATION DATE: 20060801


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (4N051/Aerospace Medical Technician) medically separated for a right knee condition. The right knee could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB). The knee condition, characterized as “chronic right knee pain with reflexive nerve character,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. The Informal PEB (IPEB) adjudicated “chronic right knee pain with reflexive nerve character, failed all treatment modalities” as unfitting, rated 0% with application of the VA Schedule for Rating Disabilities (VASRD). The IPEB also identified three conditions, not forwarded by the MEB, as Category II, conditions that can be unfitting but are not currently compensable or ratable. The CI appealed to the Formal PEB (FPEB) which increased the knee rating to 10%, and did not change the three Category II conditions. The CI was medically separated.


CI CONTENTION: The CI writes: “It has been nine years since the date of my injury and seven years since I was medically discharged. To this day I am still in constant pain on a daily basis. My pain never goes away; it never drops below a three and raises to well above a ten on the zero to ten pain scale. There is nothing I can do to make my pain better. If l had to describe my pain in words I would say that it feels like my leg is breaking at the knee joint, like someone is holding a blow torch to it; the pain is a burning, stabbing, sharp, dull, gnawing, aching feeling. I have a noticeable limp. I walk with the assistants (sic) of a cane and wear metal/titanium knee braces. I cannot run at all and when I have to walk further than a short distance I have to take several breaks in between due my pain getting worse. I have to modify the way I use the stairs. I can only do non weight bearing activities. It hurts when I go to sit down, but hurts worst when it’s time to get up. Squatting is limited and difficult, I cannot squat past a chair height position and can only get to chair height when holding on to something. My knee goes back further than it should while standing or walking, it also goes out at times. It is very difficult to get up after I fall down. When I am in severe pain I cannot function, I have to just stop whatever I am doing until the pain eases up. I have had three surgeries and the last surgery was three surgeries in one so that's a total of six procedures and nothing seems to help. My first surgery was an arthroscopy 2005, the second was a bilateral release along with another arthroscopy 2009 and the third was a tibia tubercle transposition, lateral release and arthroscope all in one 2011. I also developed blood clots in my leg after the last surgery and will remain on blood thinners for the rest of my life along with having an IVC greenfield filter in place. As for my migraine headaches when I am having a migraine I am very light and noise sensitive and even vomit at times. I have to try and block out all light and noise because they make my migraines worst and lay down. My migraines usually last for about three to four days at a time and they occur several times a month.”


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 knee condition is addressed below. The requested headaches condition, which was determined to be not unfitting by the PEB, is likewise addressed below. 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 Veterans Affairs (DVA), operating under a different set of laws. The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month 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. The Board also acknowledges the CI’s implied contention for ratings of her headache condition which was determined to be not unfitting by the PEB. Disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that any contested condition was most likely incompatible with military service, a disability rating IAW the VASRD, based on the degree of disability evidenced at separation, will be recommended.


 RATING COMPARISON :

Service FPEB – Dated 20060615
 VA - (1 Mo. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic R Knee Pain with Reflexive Nerve Character 8799-8721 10% DJD, S/P Meniscus Repair 5010 10% 20060904
Headaches Cat II Migraine Headaches 8100 30% 20060904
Other x 2 (Not in Scope)
 Other x 9 20060904
Combined: 10%
 Combined: 90%
Derived from VA Rating Decision (VA RD ) dated 200 70315 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Chronic Right Knee Pain Condition. The CI developed right knee pain as a consequence of an injury in October 2004. Continued pain in the context of negative radiographic studies led to a diagnostic arthroscopy in November 2005. Findings included a plica (redundant tissue), but no meniscal or ligament tears. Although there was some improvement in pain after excision of the plica, two subsequent falls in the post-operative period re-ignited her pain. Despite pain management and exhaustive physical therapy, she continued to use a cane for ambulation assistance as her pain did not allow her to withstand much activity. By March 2006, an orthopedist indicated that neurologically-mediated pain was present in the knee.

At the narrative summary (NARSUM) evaluation on 7 April 2006 (4 months prior to separation) the CI complained of persistent knee pain for which she used a cane to assist in walking. Physical exam showed no swelling, but mild quadriceps muscle atrophy was present. There was no tenderness of the medial or lateral joint line and no crepitus. There was hypersensitivity to light touch below the kneecap. Guarding was evident during the knee exam. There were no temperature or color changes, and neurologic exam was normal. All knee ligaments were intact.

At the VA Compensation and Pension (C&P) exam on 14 September 2006 (a month after separation), the CI reported constant pain that was aggravated by weather changes, climbing stairs, movement or touching. Sporadic swelling and buckling occurred, but there was no locking. Examination showed a slow and stiff gait with use of a cane. A brace was worn on the right knee. Swelling and mild tenderness of the right knee was present. Painful motion was present at the extremes of range-of-motion (ROM). Movements were slow due to guarding. Atrophy of the right thigh was present. Ligament testing was normal and there was no additional loss of ROM with repetition. At a VA clinic visit on 16 April 2007 (8.5 months after separation), the gait was normal. The knee displayed painful motion, but “good ROM” and no swelling. At a VA orthopedic evaluation on 16 May 2007, the CI stated that the pain was intermittent. Examination showed a stiff gait favoring the right leg and the presence of a cane in the left hand. Hyperesthesia of the right knee was noted. The examiner’s diagnosis was complex regional pain syndrome (sympathetically mediated pain condition).

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Knee ROM
(Degrees)		 MEB ~ 4 Mo s . Pre-Sep VA C&P ~1 Mo. Post-Sep
Flexion (140 Normal) 130 120
Extension (0 Normal) 0 0
Comment +Guarding, hypersensitivity +Swelling, tenderness, painful motion
§4.71a Rating 10% 10%

The Board directs attention to its rating recommendation based on the above evidence. The FPEB assigned a 10% rating under an analogous 8521 peripheral nerve code (paralysis of common peroneal nerve), while the VA used the 5010 code (arthritis due to trauma) to justify the same rating. Board members agreed that either coding pathway was defensible, given the history and physical findings in this case, but debated if a higher rating was warranted. It was noted that in the FPEB’s “Remarks” section of the AF Form 356, the condition was “best characterized as moderate.” However, the 8521 code stipulates that “moderate” incomplete paralysis justifies a 20% rating, while “mild” warrants 10%. Board members agreed the evidence at hand was most accurately described by the “moderate” descriptor and therefore a 20% rating was supported. Turning to the §4.71a pathway used by the VA, although non-compensable limitation of knee motion was present, the Board concluded that there was sufficient evidence of functional loss (§4.40) or painful motion (§4.59) to justify a 10% rating. There was no evidence of knee instability or of locking due to dislocated semilunar cartilage to warrant rating under the 5257 or 5258 codes. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic right knee pain condition, coded 8799-8721.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that headaches were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

According to the NARSUM examiner, although the CI reported a history of headaches she “otherwise feels she is healthy with the exception of her right knee.” In her letter to the PEB on 28 April 2006, the CI noted only her knee condition as a limitation to fulfillment of duty responsibilities. The commander’s statement on 4 May 2006 did not specify headaches as a cause of duty limitations or missed work. On the Report of Medical Assessment (DD Form 2697) dated 27 June 2006, the CI only indicated that the knee condition interfered with performance of her duty. At a dental C&P exam on 8 September 2006 (a month after separation) the CI stated that her headaches began in February 2006 and occurred 3-4 times per week.

The headache condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. This condition was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the headache condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the headache condition and so no additional disability rating is recommended.


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 condition, the Board unanimously recommends a disability rating of 20%, coded 8799-8721 IAW VASRD §4.124a. In the matter of the contended headaches condition, the Board unanimously recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Chronic Right Knee Pain with Reflexive Nerve Character 8799-8721 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131126, 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-2013-02546.

         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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. The office responsible for making the correction will inform you when your records have been changed.

                                                               Sincerely,






 XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachments:
1. Directive
2. Record of Proceedings

cc:
SAF/MRBR
DFAS-IN

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