RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX 		BRANCH OF SERVICE: ARMY
CASE NUMBER:  PD0900216		BOARD DATE:  20100325
SEPARATION DATE:  20070210
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SUMMARY OF CASE:  This covered individual (CI) was an active duty Captain (Health Services Administration) medically separated from the Army in 2007 after 6 years of service.  The medical basis for the separation was a left knee condition.  He graduated West Point and entered active duty in 2000 with a pre-existing soccer injury to the left knee.  He underwent reconstruction of the anterior cruciate ligament (ACL) soon after entry, followed by a revision of the ACL repair and several arthroscopic meniscal (cartilage) surgeries.   After a meniscal implant, he was cleared by a Military Occupational Specialty Medical Retention Board (MMRB) in 2002.  He successfully completed two Operation Iraqi Freedom (OIF) deployments in 2003 and 2005, but suffered progressive pain and limitations.  Ligamental stability was intact at the time of the MMRB, but anterior laxity and quadricep atrophy were documented after the deployments.  He did not respond adequately to physical therapy and protracted conservative measures.  A Magnetic Resonance Imaging (MRI) in 2006 demonstrated an intact ACL graft and meniscal implant, but there were significant degenerative changes and osteochondral pathology.  Further surgical options were discussed, but none would prevent a permanent L3 profile and he was referred for a Medical Evaluation Board (MEB).   The MEB forwarded three separate conditions to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501: chronic knee pain (noting ACL revision and graft), internal derangement, and osteoarthritis.  These were combined into a single unfitting condition by the PEB.  It was coded under the 5257 instability code and rated 20% for moderate impairment.  Additional conditions supported in the Disability Evaluation System (DES) packet, including post-traumatic (PTSD), are discussed below.  They were not forwarded for PEB adjudication on the DA Form 3947, although the PEB requested clarification of the PTSD issue prior to its decision.  The CI was medically separated with a 20% disability rating.
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CI CONTENTION:  The CI states: ‘I have received a 30% rating from the Veterans' Administration (VA) for all conditions related to the left knee impairment that deemed me unfit to serve in the U.S. Army.  I received 10% for each of the following conditions: Residuals Status Post ACL Repair Left Knee, Tender Scar as Secondary to the Residuals Status for Post ACL Repair Left Knee, and Low Back Condition with Pain and Abnormal Gait.’  He cites his current lifestyle and employment 
limitations.  He also elaborates the disadvantages and financial consequences of his circumstance without retirement benefits. ________________________________________________________________

RATING COMPARISON:

Service PEB	VA (4 Mo. after Separation) – All Effective 20070211	
Condition	Code	Rating	Date	Condition	Code	Rating	Exam	
Chronic Left Knee Pain…	5257	20%	20061102	Residuals s/p ACL Repair	5299-5010	10%	20070608	
				Tender Scar a/w Above	7804	10%	20070608	
↓No Additional DA FORM 3947 Entries.↓	Lumbar Strain	5237	10%	20070608	
	Tinnitus	6260	10%	20070608	
	Hypertension	7101	10%	20070608	
	Non-PEB X 1/ NSC X 4.  PTSD Deferred.	20070608	
TOTAL Combined:  20%	TOTAL Combined (Includes Non-PEB Conditions): 40%                                                                          	
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ANALYSIS SUMMARY:

Left Knee Condition.  The separate conditions split out on the DA Form 3947 were appropriately consolidated by the PEB.  The MEB and the VA range-of-motion (ROM) exams documented 125° and 140° respectively of knee flexion.  Thus there was no compensable ROM impairment for coding purposes.  The VA examiner documented no instability on his exam, and thus the VA rater did not apply the 5257 instability code which was justified by the MEB examination.  The VA default to the analogous 5010 code for a 10% rating was reasonable in light of the VA exam.  There is little doubt from the service record that instability was present.  The MEB examiner noted a 2A Lachman (physical test for ACL integrity) and another MEB orthopedic examiner described it as 3A.  No medial, lateral or posterior instability was documented on any exam.  The PEB ‘moderate’ designation for a 20% rating under 5257 was fair since the instability was confined to one plane and the joint was not brace-dependent.  In consideration of the fact that all of the ligaments were identified as intact by MRI, one could justify the 10% rating in strict accordance with 5257.  The associated meniscal and arthritis pathology, in addition to documented instability, justifies a dual code approach to rating this knee.  The Board considered various options in that regard.  Achieving a 20% rating under the 5258 meniscal code plus an instability rating was one such alternative.  There was no evidence, however, of persistent effusion or locking which would justify the application of the 5258 code.  Certainly a 10% rating under the 5259 cartilage code or the 5010 arthritis code could be combined with a 5257 rating.  The Board deliberated the approach of combining one of the 10% codes with a 20% rating for 5257.  After consideration it was agreed that if a dual code was applied, the arguably liberal 20% rating based on 5257 criteria alone could no longer be justified.  Since the 10% plus 10% approach would offer no advantage over the PEB adjudication, it was not further pursued by the Board.  

The CI’s contention that the VA’s surgical scar rating should be included in his service rating was considered.  The Board cannot justify the addition of a scar rating unless it impairs fitness.  Since joint mobility was unaffected and the scar did not prohibit the use of required gear, there was no such link to fitness.  The Board, therefore, has no foundation for a recommendation favorable to the CI in this regard.  It is unclear if the CI’s contention that his VA back rating should be included was based on the assumption that it was linked to his unfitting knee condition or on the conclusion that it was unfitting in itself.  There is not enough evidence to support either premise, however.  

All evidence considered, there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB adjudication for the left knee condition.

PTSD, Back Pain and Other Conditions.  The CI was diagnosed with PTSD after his return from his last OIF deployment.  He was placed on medication and treated as an outpatient.  Although not included in the narrative summary (NARSUM) or noted on the DA Form 3947, it was addressed in the MEB physical.  There is a memorandum from the PEB requesting clarification of PTSD from the MEB, although there is no psychiatric memorandum or addendum in evidence as a response.  This notwithstanding, there is no suggestion in the record that PTSD was an acute or potentially unfitting condition at separation.  The MEB physical states, ‘PTSD also developed post last rotation.  Doing better now on Zoloft 50 mg/day & Effexor 50 mg/day.  Still startle & hypervigilant though.’  An outpatient note four months prior to separation states, ‘Also reports history of PTSD (deployment related) which has been treated and is now not a clinical issue.’  The Commander’s statement indicates that he remained highly functional from a mental standpoint.  It states, ‘His performance has been outstanding...  In a garrison environment, [CI’s name] has demonstrated his ability to perform his duties despite his physical limitations.’  The physical profile was S1.  There is therefore not enough reasonable doubt in the CI’s favor supporting a Board recommendation for addition of PTSD as an unfitting condition.  

Back pain, although noted in his application, was not reported by the CI on his separation physical.  It was not contended at separation or covered by the NARSUM.  There is no evidence of active treatment for it at separation.  The condition is therefore not eligible for Board consideration under DoDI 6040.44.  Even if it were, there is nothing in the Commander’s statement, physical profile or elsewhere that would support a recommendation that it was additionally unfitting.

There were no other conditions in the DES packet relevant for Board consideration as additionally unfitting.  The VA identified tinnitus, hypertension and migraine headache as service connected conditions.  These conditions had no fitness implications and, regardless, were not identified in the DES packet.  As previously noted, the Board does not have the authority to render recommendations for any conditions not considered by the DES.  These or any other contended conditions remain eligible for Army Board for Correction of Military Records (ABMCR) consideration.  The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.
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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.  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 left knee condition and IAW VASRD §4.71a, the Board by a 2:1 vote recommends no change in the PEB adjudication.  The single voter for dissent recommended separate 10% ratings under the 5257 and 5259 codes in conformance with precedent cases and as a more accurate reflection of the pathology and disability.  This approach would not have affected the overall outcome and no minority opinion is submitted.   In the matter of PTSD 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.
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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090310, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.