RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX		BRANCH OF SERVICE: ARMY
CASE NUMBER:  PD0900181		BOARD DATE: 20100311
SEPARATION DATE: 20070101
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SUMMARY OF CASE:  This covered individual (CI) was an active duty SSG (Chemical Operations Specialist) medically separated from the Army in 2007 after 5 years of service.  The medical bases for the separation were knee and back conditions.  He entered the Army with a right knee waiver for an anterior cruciate ligament (ACL) repair at age 16.  He initially fared well with the knee but began to have pain with running and other activities in 2001.  He was noted to have some laxity of his ACL graft and was managed with a brace and L2 profile.  A subsequent Magnetic Resonance Imaging (MRI) demonstrated a meniscal (cartilage) tear and he underwent arthroscopic debridement in 2003.  He was managed with aggressive conservative measures and his physical limitations were accommodated because of his strong performance as a soldier.  He successfully completed deployments to Operation Iraqi Freedom (OIF) and Kuwait.  In 2005 he underwent arthroscopic reconstruction of his ACL utilizing a hamstring autograft.  He still required a profile and suffered continued pain and physical limitations.  An MRI in 2006 showed laxity of the ACL graft and degenerative changes.  There were no further surgical options and, despite continued conservative measures, he required a permanent L3 profile.  His knee problem was compounded by the development of low back pain starting in 2002 after a motor vehicle accident in Kuwait.  This gradually worsened over the ensuing years in service, but was overshadowed by the knee issues and required no additional pain medication.  He received a more directed evaluation and physical therapy (PT) in 2006.  An MRI at that time showed a mild disc bulge at L1/2 and mild facet degeneration at L4/5.  He had occasional right sciatic radicular pain, but did not have motor weakness or a distinct clinical radiculopathy.  He was not a surgical candidate and his back condition was incorporated into the L3 profile.  He underwent a Medical Evaluation Board (MEB) for both the right knee and lumbar conditions.  Each of the conditions was judged to be medically unacceptable IAW AR 40-501 and forwarded to the Physical Evaluation Board (PEB).  Two other conditions, allergic rhinitis and gastroesophageal reflux disease (GERD), were forwarded on the DA Form 3947 as medically acceptable conditions.  The PEB found the CI unfit for the right knee and back conditions, rated 10% each.  The other conditions were adjudicated as not unfitting, and he was medically separated with a combined rating of 20%.
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CI CONTENTION:  The CI states: ‘VA increased disability 80% overall-Had to have surgery on Back condition and Knees.’  He elaborates no specific contentions regarding rating or coding and mentions no additionally contended conditions.

RATING COMPARISON:

Service PEB	VA (6 Mo. after Separation) – All Effective 20070102	
Condition	Code	Rating	Date	Condition	Code	Rating	Exam	
Osteoarthritis, Right Knee…	5003	10%	20061031	S/P Right Knee Surgery…	5010-5257	30%	20070608	
Chronic Back Pain …	5299 5237	10%	20061031	Deg. Disk Disease, Lumbar Spine	5242	20%	20070608	
Seasonal Rhinitis	Not Unfitting	20061031	Allergic Rhinitis	6522	0%	20070608	
GERD	Not Unfitting	20061031	GERD w/ Hiatal Hernia	7346	10%	20070608	
No Additional DA 3947 Entries.	Left Knee Patellar DJD	7346 	10%	20070608	
TOTAL Combined:  20%	TOTAL Combined (Includes Non-PEB Conditions): 60%                                                                          	
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ANALYSIS SUMMARY:

Right Knee Condition.  The narrative summary (NARSUM) physical examination of the knee referred to the handwritten DD Form 2808 exam which is difficult to decipher, although quadriceps atrophy was clearly documented.  A PT goniometric range-of-motion (ROM) exam documented 125° active flexion.  Anterior (i.e., ACL) laxity was documented in outpatient notes, although intact medial/lateral and posterior stability were described.  The VA rating examiner noted pain at 90° flexion, ‘severe’ anterior/posterior instability and ‘slight’ medial/lateral instability.  The use of a brace and cane were documented.  There was crepitus, but no effusion or other significant physical findings.  The PEB coded the knee under the 5003 arthritis code and the DA Form 199 specified ‘without instability’ and ‘non-compensable limitation of motion’.  The VA applied the 5257 code for instability with a 30% rating as ‘severe’.  The Board does not share the PEB’s opinion that there was no instability.  The NARSUM physical is not an adequate source for a definitive ligament exam.  The NARSUM contains the MRI report noting ACL laxity and the CI’s history that the knee ‘does not feel stable’.  The intermittent requirement for a brace had been present for several years prior to separation.  On the other hand, the Board does not see corroboration in the service record for the ‘severe’ laxity opined by the VA examiner.  The VA description of laxity in the posterior, lateral and medial planes is contradicted by several valid examinations in the service record.  Since anterior laxity was adequately demonstrated by the MEB, in addition to significant meniscal and degenerative pathology, the Board believes that optimal rating must include dual codes.  This approach would easily justify a 10% rating under either the 5010 arthritis code (painful motion) or the 5259 menisectomy code plus at least a 10% rating under the 5257 code.  Consolidation of all the disability into a 30% rating under the 5257 code (as per the VA) was considered.  It was judged, however, that the instability inherent to isolated ACL laxity could not be characterized as ‘severe’.  Finally, consideration was given to a 10% 5259 rating plus a 20% 5257 rating.  After deliberation, it was decided that the dual coding approach mandated conservative ratings for each component and that the 5257 rating should be constrained to 10%.  The Board therefore recommends that the knee be rated as 10% under 5259 plus 10% under 5257.

Back  Condition.  There are goniometric exams from PT and the VA rating examiner available to the Board for application to its rating recommendation.  In addition there are specific ROM’s from the MEB examiner in an addendum to the NARSUM.  This states, ‘Range of motion: flexion greater than 90°, extension 15°, levo- and dextroflexion greater than 30°, levo- and dextrorotation greater than 30° Goniometry was performed and recorded as the official measurements by Physical Therapy (PT).’  The two formal exams are summarized in the table below.

Thoracolumbar ROM	P.T. – 8/8/06	VA C&P – 6/8/07	
Flexion	85⁰	70⁰	
Combined	215⁰	125⁰	
§4.71a Rating	10%	10% (Rated 20% for antalgic gait.)	

The PEB’s DA Form 199 invoked application of the US Army Physical Disability Agency (USAPDA) pain policy for rating, but the 10% rating determination would have been unaffected by rating strictly IAW Veterans Administration Schedule for Rating Disabilities (VASRD) §4.71a.  The ROM measurements by the VA examiner, in themselves, would have provided for a 10% rating.  There were no informal ROM examinations in evidence suggesting that the goniometric exams were not reflective of a fair rating.  The VA rating decision noted application of antalgic gait to satisfy the 20% rating requirement.  There is ample evidence, however, that antalgic gait was attributable to the knee rather than the back.  The VA examiner’s notation of antalgic gait is not found in the spine examination, but referred to in the knee examination.  Intermittent antalgic gait and the use of a cane and brace for the knee are evident in PT notes, as well as some entries noting normal gait.  A note from the CI’s pain management physician states that the back symptoms were ‘attributed by the patient to his altered gait required for his right knee pain’ and in the physical exam states ‘The gait is antalgic, favoring right lower extremity.’  A PT note also states ‘A right-sided antalgic gait was observed.’  The favorable ROM’s and the normal straight leg raising tests in evidence are not clinically consistent with the degree of thoracolumbar spasm which would be expected to alter gait.  There is not reasonable doubt in the CI’s favor, therefore, to apply abnormal gait to achieve a 20% thoracolumbar rating.  There was no evidence of ratable peripheral nerve impairment in this case.  The Board, therefore, believes that the rating for the back pain was fairly adjudicated by the PEB.  It prefers the 5242 VASRD code as more specific to the pathology.

Other DA 3947 Conditions (Seasonal Rhinitis, GERD).  Neither of these conditions was clinically acute at the time of separation and both met AR 40-501 retention standards.  Both are common ailments without anticipated implications regarding fitness.  Neither was mentioned in the Commander’s statement or in the physical profile.  There is no reasonable foundation for a Board recommendation to add either of these conditions as unfitting for separation rating.
 
Other Conditions.  A few minor conditions were mentioned in the NARSUM and/or noted on the MEB physical, but none are relevant for Board consideration as additionally unfitting.  The VA applied a compensable rating for the CI’s left knee based on degenerative disease of the patella from the tendon graft harvest in his youth.  There were no abnormal physical findings or symptoms attributable to the left knee documented in the Disability Evaluation System (DES) packet.  A subsequent diagnosis of post-traumatic stress disorder (PTSD) was made by the VA.  The rating was not retroactive to separation.  A history of Obsessive-Compulsive Disorder (OCD), panic attacks and insomnia was noted on the MEB physical.  There was no active psychiatric treatment at the time of separation.  The laudatory Commander’s statement would dispel any doubts regarding mental health fitness.  There were no PTSD-specific symptoms related at the time of the MEB physical or on the post-deployment health assessment.  PTSD was not established as a diagnosis eligible for DES consideration and the diagnosed mental health conditions were not unfitting.  The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES.  PTSD or any other contended conditions, except for those already discussed, remain eligible for Army Board of Correction for Military Records (ABCMR) consideration.  
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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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the back condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right knee condition, the Board by a 2:1 vote recommends that it be rated under separate codes as follows: 5259 rated 10% and 5257 rated 10%, IAW VASRD §4.71a.  The single voter for dissent (who recommended 5259 at 10% plus 5257 at 20%) did not elect to submit a minority opinion.  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB rating adjudication.  A more specific description and VASRD code for the back condition is offered in our summary chart.  In the matter of the seasonal rhinitis, gastroesophageal reflux disease or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.

RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation.
 
UNFITTING CONDITION	VASRD CODE	RATING	
Right Knee Impairment From Meniscal Injury and Surgical Residuals	5259	10%	
Right Knee Impairment From Instability of the Anterior Cruciate Ligament	5257	10%	
Lumbar Spine Degenerative Arthritis and Disc Disease 	5242	10%	
COMBINED	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090218, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.