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AF | PDBR | CY2013 | PD-2013-02778
Original file (PD-2013-02778.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02778
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20150609
SEPARATION DATE: 20070621


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E-5 (Aerospace Control and Warning Craftsman) medically separated for bilateral knee pain. The bilateral 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 a temporary L4 profile and referred for a Medical Evaluation Board (MEB). Left knee pain was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other condition was submitted by the MEB. The Informal PEB adjudicated bilateral knee pain due to patellofemoral syndrome and osteoarthritis with effusions as unfitting, rated 20% c iting application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI appealed to the Formal board (FPEB), but no CI rebuttal or FPEB documents were found. The CI was medically separated.


CI CONTENTION: The CI elaborated no specific contention in her application.


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any condition outside the Board’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. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board 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, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


 RATING COMPARISON :

IPEB – Dated 20070413
 VA* - (~13 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Knee Pain … 5099-5003 20% PFS of the Left Knee 5260 10% 20080702
PFS of the Right Knee 5260 10%
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 5
RATING: 20%
 RATING: 40%
* Derived from VA Rating Decision (VA RD ) dated 200 80922 (most proximate to date of separation [ DOS ] )



ANALYSIS SUMMARY:

Bilateral Knee Pain. The first record in evidence for the bilateral knee pain was a duty excuse, dated 5 April 2002, from her civilian physician stating that she should not participate in running or prolonged standing due to knee and ankle pain. A physical therapy (PT) note dated 7 May 2002 documented that her bilateral knee pain was secondary to abnormal tracking of the patella (kneecap). An orthopedist noted on 17 June 2002 that she had reached maximal medical benefit and that she had permanent changes in her knees. Also, he wrote that activities such as squatting, climbing up and down stairs, and bending her knees would increase her symptoms. The CI was issued a profile, but was able to continue duty. She deployed in February 2006 and was seen on 13 February 2006 for increased left knee pain without recent injury. She was managed with duty restrictions, medications, and PT. A magnetic resonance image (MRI) performed on 22 April 2006 showed mild degenerative changes of the lateral meniscus (a cartilage cushion) of the left knee, but was otherwise unremarkable. The next day, she was noted to have normal range-of-motion (ROM) and gait; provocative testing for meniscal irritation was positive. The knee was stable and no effusion was present. X-rays completed on 13 June 2006 were normal for both knees. She was diagnosed with bilateral patellofemoral syndrome (PFS) that day in orthopedics. Her examination was essentially normal with a stable knee, normal gait, and absent signs of meniscal irritation. The patella was tender to palpation. She was also noted to have genu valgus (knock-knees), a congenital condition (in the absence of trauma) which can lead to knee pain and arthritis.

At the VA’s primary care exam on 13 October 2006 she was noted to have a normal gait and to free of an effusion. Her patellae were mobile with mild crepitus (a physical or audible grating seen in degenerative disease such as PFS). She failed to improve despite medications, duty limitations, and PT. She was not thought to have a surgically treatable condition and was referred to MEB. At the VA Compensation and Pension (C&P) examination performed 8 months before separation from the Guard, the CI reported that her pain started in February 2006. The Board observed that her knee pain began at least 4 years prior to that. She endorsed bilateral locking, buckling, popping, and grinding and the use of a knee brace bilaterally as well as crutches. On examination, she had crepitus bilaterally, but her gait was normal and instability absent. The ROM was reduced as charted below. DeLuca criteria were negative. X-rays were normal.

The MEB narrative summary (NARSUM) was dated 20 January 2007 and noted that her pain had worsened since her deployment in February 2006. On examination, she was noted to have reduced ROM secondary to pain, patellae which could be dislocated to the outside, and marked crepitus. Moderate effusions were thought to present. She was diagnosed with severe osteoarthritis with effusions; the action officer noted that osteoarthritis was not seen on X-rays or MRI and that orthopedics had diagnosed bilateral PFS.

At the VA Compensation and Pension (C&P) examination performed just over 12 months after separation, the CI reported that her knee pain began gradually in April 2006 without antecedent trauma. She again endorsed bilateral locking, buckling, popping, and grinding, but denied the use of a knee brace or crutches bilaterally. On examination, she had a slight limp, but used no assistive devices. The ROM was reduced as below. There was no instability or swelling. Palpation was not tender. Muscle atrophy was absent and her strength was normal. X-rays were again normal. DeLuca criteria were recorded as present for flexion of the left knee, but the additional limitations not documented.

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.

Knee ROM
 (Degrees)
 PT
 ~ 10 Mo. Pre-Sep		 2006 VA C&P
 ~ 8 Mo. Pre -Sep		 MEB
 ~ 5 Mo. Pre-Sep		 2008 VA C&P
 ~ 13 Mo. Post -Sep
Left Right Left Right Left Right Left Right
Flexion (140 Normal)
 130 -- 140 140 125 120 60 100
Extension (0 Normal)
 0 -- 0 0 0 0 0 0
Comment
 No Pain; Noted as full AO Painful Motion Painful Motion Limited by pain Limited by pain + DeLuca. Limited by pain Limited by pain
§4.71a Rating
 0 % --- 10 % 10 % 10 % 10 % 10 % 10 %

The Board directed its attention to its rating recommendation based on the above evidence. The PEB bundled the knee conditions together for rating as a single condition at 20% using the analogous code 5003 (degenerative arthritis). The VA rated each knee at 10% using the code 5260 (limitation in flexion). Absent instability, the Board found no route to a rating higher than 10% for each knee. It noted that each knee could be unbundled and rated separately. This provides no rating advantage to the CI though. 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 bilateral 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 bilateral knee pain 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 20131217, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762
XXXXXXXXXXXXXXXXX

Dear XXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02778 .

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,







XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR

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