BOARD DATE: 23 January 2018 DOCKET NUMBER: AR20170000287 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ____x____ ___x_____ ____x____ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration BOARD DATE: 23 January 2018 DOCKET NUMBER: AR20170000287 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined that the overall merits of this case are insufficient as a basis to amend the decision of the ABCMR set forth in Docket Number AR20140013883 on 7 April 2015. ______________x___________ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. BOARD DATE: 23 January 2018 DOCKET NUMBER: AR20170000287 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests reconsideration of his earlier request for correction of his military records to show he was honorably discharged by reason of disability with entitlement to veterans benefits. 2. The applicant states he did not receive the proper medical treatment for his right knee. Discharge was not his intent, as stated. He also states: a. He is appealing the Board's decision on a "pre-existing" injury. There is no denying that he previously had anterior cruciate ligament (ACL) reconstruction, but that did not lead to his discharge from the Army. What happened is Army doctors at Reynolds Army Community Hospital, Fort Sill, OK, took advantage of him. He has provided multiple documents from the hospital stating he had a lateral collateral ligament (LCL) sprain/tear. A page marked with stars states, "Right Knee, Effusion, tenderness on palpation over LCL, pain was elicited by motion." It also states the ACL, posterior cruciate ligament (PCL), medial cruciate ligament (MCL), and crepitus (grating sound or sensation produced by friction between bone and cartilage) were all negative. He has included multiple documents defining particular tests they performed and the definition of crepitus. This most importantly was negative. b. On the same page under "Objective," it states, “There appears to be laxity in the right LCL and I am concerned [applicant] may have an LCL strain or tear. Patient be placed in a long leg knee immobilizer, given crutches and be provided pain medication.” He states he was not provided a long leg knee immobilizer at all. c. His next concern is his meetings with Dr. Jo__ Lo__ (Family Medicine), who, in effect, made it appear as if his injuries were pre-existing. He did not want to leave or be discharged. The way the doctor put it was entrapment and taking advantage of a young Soldier who did not know the system. d. He feels that he did not receive proper treatment/care for a possible LCL strain/sprain or tear. Magnetic resonance imaging should have been performed to properly diagnose his right knee. He has experienced approximately 2 years of ongoing issues with his knee and he is afraid to see what excessive damage has occurred due to the lack of treatment on his right knee. He requests a reversal of the Board's previous decision. He wants an honorable discharge and veteran benefits with a disability. e. He also wants someone held accountable for his pain and suffering, due to the lack of medical treatment. If we cannot come to an agreement, next time he will be represented by his lawyer. 3. The applicant provides: * Standard Form (SF) 600 (Chronological Record of Medical Care), dated 20 July 2013 and 24 July 2013 * Consultation Report, dated 25 July 2013 * Website descriptions of crepitus, the Lachman test, the drawer test, drawer sign, and LCL tears CONSIDERATION OF EVIDENCE: 1. Incorporated herein by reference are military records which were summarized in the previous consideration of the applicant's case by the Army Board for Correction of Military Records (ABCMR) in Docket Number AR20140013883 on 7 April 2015 2. The applicant provides a new argument as well as multiple internet printouts regarding crepitus, LCL, and various medical tests. This new evidence warrants consideration by the Board. 3. In preparation for his enlistment in the Regular Army, and prior to his medical examination, the applicant completed a DD Form 2807-2 (Medical Prescreen of Medical History Report) on 22 February 2013. This medical form shows in: a. Item 2 (Mark each item "Yes" or "No," every item marked "Yes" must be fully explained in 2(b)), in response to the question in 2(a) (Have you ever had or do you now have), the applicant marked "Yes" for the question related to surgery on a bone or joint, and explained, "30 May 2002, age 16, Treatment Facility: The Children's Hospital of Philadelphia, PA; Explanation: Right knee ACL reconstruction using soft tissue cryolife tendoachilles allograft with press fit technique distally and staple fixation proximal to the level of the physis in a skeletally immature patient: Doctor: Ga__." b. Item 10 (Physician's Summary and Elaboration of All Pertinent Data), in pertinent part, the physician entered comments that the applicant answered "anterior cruciate ligament rupture [right], repair of tear, reconstruction [with] allograft [30 May 2002]." 4. The applicant underwent an enlistment physical on 12 March 2013 at the Harrisburg, PA, Military Entrance Procession Station (MEPS). The DD Form 2808 (Report of Medical Examination) completed at the MEPS shows in: * item 74 (Examinee/Applicant): he was found qualified for military service * item 77 (Summary of Defects and Diagnoses): "[Right] ACL reconstruction [with] allograft [30 May 2002] fix rupture, no hardware" * item 78 (Recommendations – Further Specialist Examinations Indicated): "[Orthopedic] consult – right knee stable and cleared for military duty – 29 May 2013" 5. The applicant enlisted in the U.S. Army Reserve under the Delayed Entry Program (DEP) on 18 June 2013. He was discharged from the DEP on 7 July 2013 and subsequently enlisted in the Regular Army for 3 years and 18 weeks on 8 July 2013. 6. He was assigned to B Battery, 1st Battalion, 79th Field Artillery (Basic Training), Fort Sill, OK, for completion of training. During the first few weeks of training, he complained of right knee pain. 7. His records contain a DA Form 4707 (Entrance Physical Standards Board (EPSBD) Proceedings), dated 29 July 2013. This form shows: a. Complaint: Right knee pain, history of prior surgery. b. History of Present Illness: Army Soldier with a history of right knee ACL reconstruction in 2001 as a result of an injury in 2000. This was disclosed to the MEPS and he was sent for an orthopedic consult and was allowed to enlist without a waiver. He admits to doing well with his knee, but did not participate in strenuous physical activity. He does admit to starting with some knee pain when preparing to come to [basic combat training], especially with running. He admits to some right knee pain while in reception due to marching and prolonged standing. He was seen in the [emergency room] after he had sharp pain in his right knee and a feeling of weakness with normal training activities. He sustained no injury to his knee while at Fort Sill. He has pain with any type of strenuous activity. An x-ray of the right knee showed evidence of previous right ACL reconstruction along with osteoarthritis in both the medial and lateral joint compartments. Due to his previous history and current symptoms which will prevent satisfactory completion of training, [existed prior to service (EPTS)] is recommended. c. Diagnosis: Right knee pain and osteoarthritis of the right knee. d. Disposition: The applicant did not meet medical fitness standards for enlistment or induction under the provisions of paragraph 2(10) (d) (1) and paragraph 2-11(c) of chapter 2 of AR 40-501 (Standards of Medical Fitness) and paragraph 19(a) (1) and 20(d) of Department of Defense Instruction (DODI) 6130.03 (Medical Standards for Appointment, Enlistment, or Induction in the Military Services). He understands they will need follow up after discharge from the military for these chronic pre-existing conditions. e. EPTS: Yes; Service Aggravated: No, Approximate date of origin: original injury in 2000 with surgery in 2001. f. The medical doctor indicated after careful consideration of the medical records, laboratory, findings and medical examinations, the EPSBD found the service member was medically unfit for appointment or enlistment in accordance with current medical fitness standards and in the opinion of the evaluating physicians he had an EPTS condition. g. The medical approving authority approved the findings of the board and forwarded the EPSBD to the applicant's commander for disposition. 8. On 7 August 2013, the applicant was counseled by his immediate commander who informed him of the medical findings of the EPSBD and of the proposed separation under the provisions of AR 635-200 (Active Duty Enlisted Administrative Separations), chapter 5 (Separation for Convenience of the Government), paragraph 5-11, based on separation of personnel who did not meet procurement medical fitness standards. a. The applicant acknowledged that he was informed of the medical findings. He also acknowledged he understood that legal advice of an attorney employed by the Army was available to him and that he could consult with civilian counsel at his own expense. He further acknowledged he understood he could request to be discharged from the Army without delay or request retention on active duty. After counseling, the applicant concurred with the proceedings and requested to be discharged from the Army without delay. b. The applicant's immediate commander recommended the applicant be discharged. On 9 August 2013, the separation authority approved the applicant's separation from the Army under the provisions of AR 635-200, paragraph 5-11, by reason of failure to meet procurement medical fitness standards. 9. On 21 August 2013, Headquarters, U.S. Army Garrison, Fort Sill, published Orders 233-1337 reassigning him to the U.S. Army Transition Center for separation processing, effective 23 August 2013. 10. The applicant was discharged on 23 August 2013. His DD Form 214 (Certificate of Release or Discharge from Active Duty) shows he was discharged under the provisions of AR 635-200, paragraph 5-11. The narrative reason for separation shows "FAILED MEDICAL/PHYSICAL/PROCUREMENT STANDARDS" and his service was uncharacterized. He completed 1 month and 16 days (46 days) of active service. 11. On 27 August 2013, he petitioned the Army Discharge Review Board (ADRB) for an upgrade of his discharge and entitlement to veterans' benefits. On 14 May 2014, the ADRB informed him the board had determined the reason for his discharge and the character of his service were both proper and equitable. The ADRB denied his request. 12. On 24 July 2014 (AR20140013883), he petitioned this Board for correction of his records to show he was medically discharged. On 7 April 2015, the Board determined that the evidence presented did not demonstrate the existence of an error or injustice. The Board denied his request. 13. He provides Chronological Record of Medical Care, a Consultation Report, as well as descriptions of crepitus, LCL, and medical tests. The Case Management Division of the Army Review Boards Agency (ARBA) forwarded his case, together with his evidence, to the Office of The Surgeon General for review. As a result, a medical officer at the Integrated Disability Evaluation System, Darnell Army Medical Center, rendered an advisory opinion in the applicant's case. He stated: a. ARBA has requested an advisory opinion regarding whether the applicant requires correction to his military record in the form of a medical evaluation board and physical evaluation board for the diagnosis of right knee pain, specifically LCL injury. All electronic medical records, including one radiology report and a hand-written SF 600 emergency room encounter were reviewed. b. Background: The applicant served on active duty from 8 July 2013 through 23 August 2013, approximately one month and sixteen days. His past medical and surgical history, predating enlistment and his MEPS physical, included traumatic right ACL tear in 2000 and subsequent reconstruction in 2001 During his MEPS evaluation, this was disclosed and he was seen by Orthopedics. The record reflects that the applicant related to the examiners that his knee was "doing well" and we later learn he was not doing much strenuous activity involving the lower extremities prior to entry onto active duty. He was cleared for entry without waiver. (1) Within a few days of beginning Army physical training in preparation for BCT, the applicant started experiencing right lateral and posterior knee pain. Running, marching, and prolonged standing all irritated his right knee. On 20 July 2013, his squad was performing calisthenics, and during a transition from lying on his back to a standing position, he felt a sharp pain in his right lateral knee. Of special note there was no fall, twist or blow involving the right knee. Any strenuous lower extremity activity from that point on bothered him above his baseline pain. (2) That same day, the applicant was seen in the Reynolds Army Community Hospital ER by provider T.M. Wa__. Provider Wa__'s exam revealed a small effusion, lateral knee tenderness and some questionable laxity of the right knee ligaments (not noted by subsequent examiners). An x-ray was obtained revealing bi-compartmental osteoarthritis and a large 6mm by 3mm loose bone fragment in the right lateral knee joint space. The ACL repair hardware was seen but the radiologist also noted metal fragments in the right knee soft tissue which had resulted from the ACL surgery. Provider Wa__ ordered and orchestrated a conservative management plan for a presumed diagnosis of LCL sprain. (3) On 22 July 2013, Provider C.J. Mo___ saw the patient briefly, carried forward the diagnosis of LCL sprain/right knee pain, and referred him to Physical Therapy. The physical therapist, B.L. Ch___, wrote in her note on 25 July 2013 that the patient had a "good response to PT," reported no bruising or effusion on her exam, noted right lateral and posterior knee pain, prepared a limited 2 week profile, and diagnosed not a ligament sprain or tear, but rather a right knee contractile issue secondary to underlying osteoarthritis. A "good prognosis" was rendered with no swelling noted and no abnormal right knee joint laxity, and the therapist noted that the applicant could ambulate normally without assistive devices. A neoprene knee sleeve was provided for support. (4) On 29 July 2013, the applicant was seen by Provider J.C. Lo___ for an EPTS exam and based on the history and above findings, it was determined that he met criteria for EPTS processing and was precluded from participating in any running, jumping, marching or prolonged standing. Only walking at own pace and distance was authorized. The Reynolds Army Community Hospital Deputy Commander for Clinical Services approved and signed the DA Form 4707 on 30 July 2013 and the applicant concurred and signed the document on 7 August 2013. By 12 August 2013, Provider S.E. Ar__ saw the applicant for discussion of transferring him to Medical Hold and the case was discussed with Major Po___. The DD Form 214 was completed and signed on 23 August 2013. c. Discussion: On 20 July 2013, the applicant was seen in the local post ER by Provider Wa__. An x-ray was done, revealing no "fat-pad" (unique radiographic density specific to fresh blood) that, if present, would indicate an acute fracture, tear of muscle or ligament damage. The x-ray also revealed metallic debris from the ACL reconstruction surgery and a large, free floating bone fragment in the right lateral knee compartment. The author of this advisory opinion is unable to explain why Provider Wa__ did not comment on the bone fragment. It appears he wrote his note before the x-ray was done and did not go back and amend his note or diagnosis. Lateral collateral sprain was the working diagnosis and was accepted/adopted by some subsequent providers despite evidence to the contrary. (1) Physical therapists are experts in bone and joint injuries and it is important to note that Therapist Ch___ did not adopt the working diagnosis, but rather formulated her own diagnosis based on history, exam and radiologic findings -- osteoarthritis. An excerpt from International Orthopedics (volume 30, issue 2, 2006) states, "Degenerative osteoarthritis was found in 25 knees, and in 24, more advanced osteoarthritis was seen in the knee joint that had underwent ACL reconstruction. The remaining cases showed similar levels of osteoarthritis on both sides. In 25 cases osteoarthritis was found in the medial compartment of the knee joint, and 14 cases also had lateral compartment osteoarthritis. Author Johma, et al., in another article found a 72 percent prevalence rate in osteoarthritis following ACL reconstruction. (2) The LCL would not suddenly sustain a sprain or tear while the applicant was simply standing up. Greater force is required and LCL injuries are often associated with ACL tears. Spindler, et al., in "ACL tear" (New England Journal of Medicine 2008), noted that approximately 60 to 75 percent of ACL injuries are associated with meniscal tears, up to 46 percent have collateral ligament injuries, and 5 to 24 percent are associated with a complete tear of a collateral ligament. (3) Likewise, a large bone fragment would not suddenly avulse off of the larger parent bone by simply standing. Avulsion fractures occur during heavy, acute trauma, and are also seen in conjunction with ACL injuries. While reading the Journal of Orthopedic Traumatology (September 2008, pp. 167-169), one sees notes about Segond's fracture; this fracture results in a small avulsed bone fragment, elliptical in shape, lying immediately below the external tibial plateau, often a few millimeters from the lateral tibial cortex. From a clinical point of view, this fracture is important, as it is often combined with other injuries: tear of the ACL at the site of femoral attachment, avulsion fragmentation of the fibular (lateral) collateral ligament at its distal attachment, and more rarely, sprain of the tibiofibular joint. d. Conclusion: The applicant had lateral and posterior knee pain prior to enlistment, which explains why he admittedly had previously not been engaging in strenuous physical activity. Patients who suffer ACL tears often sustain associated internal knee derangements, especially when the injury occurs at a younger age. The development of joint osteoarthritis is time-dependent and the applicant was more than a decade out from his injury and surgery. Loose bone fragments in joints are free floating. They move about depending on position, synovial fluid and activity. The x-ray revealed a large fragment in the lateral aspect of his knee and was most likely the source of his sharp pain on 20 July 2013. The service member's right knee problem was, in fact, EPTS and was not permanently aggravated by his brief tour of service. e. Recommendation: The applicant is not eligible for a medical evaluation board for his right knee problems. The rationale here is that a MEPS examination is not sufficient to determine maximal joint activity and stress tolerance of a specific joint. Its purpose is to assess general fitness for enlistment. The enlistee in question reported that his knee was "doing ok" and a basic exam by the orthopedic examiner was normal but limited to a joint that had not been heavily loaded, stressed or tested in years. A waiver was not issued. (1) AR 40-501, paragraphs 2-10(1), 2-11c, 2-19a(1) and 2-20d, all essentially state that a chronic lower extremity problem (i.e., knee) that interferes with function enough to preclude a physically active vocation or that would interfere with walking, running, weight bearing or completion of military training, do not meet the standard for enlistment. (2) AR 635-200, paragraph 5-11(a), reads that Soldiers who were not medically qualified under procurement medical fitness standards when accepted for enlistment or who became medically disqualified under these standards prior to entry onto active duty for initial training, may be separated. These conditions must be discovered during the first six months of active duty. (3) AR 635-200, paragraph 5-11(b), reads that medical proceedings must establish that a medical condition was identified by an appropriate military medical authority within 6 months of the Soldier's initial entrance onto active duty. All of these apply to the applicant. 14. The applicant was provided with a copy of this advisory opinion to give him an opportunity to submit a rebuttal. He did not respond. REFERENCES: 1. AR 635-200 sets forth the basic authority for separation of enlisted personnel. a. Paragraph 5-11 specifically provides that Soldiers who are not medically qualified under procurement medical fitness standards when accepted for enlistment, or who became medically disqualified under these standards prior to entry on active duty, active duty for training, or initial entry training will be separated. A medical proceeding conducted by an EPSBD, regardless of the date completed, must establish that a medical condition was identified by appropriate medical authority within 6 months of the Soldier's initial entrance on active duty, the condition would have permanently or temporarily disqualified the Soldier for entry into the military service had it been detected at the time of enlistment, and the medical condition does not disqualify the Soldier from retention in the service under the provisions of AR 40-501, chapter 3. The characterization of service for Soldiers separated under this provision will normally be honorable, but will be uncharacterized if the Soldier has not completed more than 180 days of creditable continuous active duty service prior to the initiation of separation action. b. An uncharacterized separation is an entry-level separation. A separation will be described as an entry-level separation if processing is initiated while a member is in entry-level status, except when characterization under other than honorable conditions is authorized by the reason for separation and is warranted by the circumstances of the case or when the Secretary of the Army, on a case-by-case basis, determines that characterization of service as honorable is clearly warranted by the presence of unusual circumstances involving personal conduct and performance of duty. c. Paragraph 3-7a states that an honorable discharge is a separation with honor and entitles the recipient to benefits provided by law. The honorable characterization is appropriate when the quality of the member's service generally has met the standards of acceptable conduct and performance of duty for Army personnel or is otherwise so meritorious that any other characterization would be clearly inappropriate. 2. AR 635-40 (Physical Evaluation for Retention, Retirement, or Separation) governs the evaluation of physical fitness of Soldiers who may be unfit to perform their military duties because of physical disability. It states according to accepted medical principles, certain abnormalities and residual conditions exist that, when discovered, lead to the conclusion they must have existed or have started before the individual entered military service. Examples are manifestation of lesions or symptoms of chronic disease from date of entry on active military service (or so close to that date of entry that the disease could not have started in so short a period) will be accepted as proof that the disease existed prior to entrance into active military service. 3. AR 40-501 governs medical fitness standards for enlistment, induction, appointment, retention, and separation. Chapter 2 provides the physical standards for enlistment/induction. This chapter prescribes the medical conditions and physical defects that are causes for rejection for appointment, enlistment, and induction into military service. Unless otherwise stipulated, the conditions listed in this chapter are those that would be disqualifying by virtue of current diagnosis, or for which the candidate has a verified past medical history. Other standards may be prescribed by DOD in the event of mobilization or a national emergency. a. Paragraph 2-10(1), current joint ranges of motion less than the measurements listed in this paragraph do not meet the standard, and includes non-acceptable measurements for the hips, knees, feet and ankles. b. Paragraph 2-11(c), a current or history of chronic osteoarthritis or traumatic arthritis of isolated joints of more than a minimal degree that has interfered with the following of a physically active vocation in civilian life, or that prevents the satisfactory performance of military duty does not meet the standard. DISCUSSION: 1. The evidence of record shows medical authorities determined the applicant suffered from a disqualifying EPTS medical condition shortly after reporting for active duty. According to accepted medical principles, the manifestation of a chronic disease from the date of entry into active military service (or so close to that date of entry that the disease could not have started in so short a period) is accepted as proof the disease existed prior to entrance into active military service. 2. His records were evaluated by an EPSBD that found him medically unfit for a condition that was neither incurred in nor aggravated by his active service. There was compelling evidence to support a finding that he had a preexisting condition. Accordingly, the EPSBD recommended his separation. He was counseled and advised of his rights, and he elected a discharge from the Army without delay. All his rights were fully protected throughout the separation process. 3. A medical review of his case determined the following: a. He had lateral and posterior knee pain prior to enlistment, which explains why he admittedly had previously not been engaging in strenuous physical activity. Patients who suffer ACL tears often sustain associated internal knee derangements, especially when the injury occurs at a younger age. The development of joint osteoarthritis is time-dependent and the applicant was more than a decade out from his injury and surgery. Loose bone fragments in joints are free floating. They move about depending on the position, synovial fluid and activity. The x-ray revealed a large fragment in the lateral aspect of his knee and was most likely the source of his sharp pain on 20 July 2013. His right knee problem was an EPTS condition and was not permanently aggravated by his active service. b. He was not eligible for a medical evaluation board for his right knee problems because the MEPS medical examination is not sufficient to determine maximal joint activity and stress tolerance of a specific joint. Its purpose is to assess general fitness for enlistment. The applicant reported that his knee was "doing ok" and a basic examination by the orthopedic examiner was normal, but limited to a joint that had not been heavily loaded, stressed or tested in years. A waiver was not issued. 4. As for the characterization of his service, a member's service is under review during the first 180 days of continuous active military service. When separated within the first 180 days, service is usually not characterized unless the circumstances of the separation warrant a discharge under other than honorable conditions. An honorable characterization may be issued only if the service clearly warrants that characterization by unusual circumstances of personal conduct and performance of military duty and is approved by the Secretary of the Army. 5. In all other circumstances, an uncharacterized separation is issued regardless of the reason for separation. An uncharacterized discharge is neither positive nor negative; it is not derogatory. It simply means the Soldier did not serve on active duty long enough for his or her service to be rated. The characterization of service he received was in compliance with the governing regulation. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20170000287 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20170000287 12 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2