RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	 CASE:  PD-2013-00258	
BRANCH OF SERVICE:  Army  	 BOARD DATE:  20141119
SEPARATION DATE:  20050316 

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an activated National Guard SSG/E-6 (88M, Motor Transport Operator) medically separated for right knee and right elbow conditions.  These conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards.  He was issued a permanent U3-L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions were characterized as “right elbow pain and stiffness… and “right knee pain and stiffness” by the MEB and forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The PEB adjudicated “right knee pain…” and “right elbow pain….” as unfitting, rated 10% and ---%, respectively (with the latter determined to have existed prior to service [EPTS]).  The right knee was likely rated in accordance with (IAW) the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The rating for the right elbow referenced the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated. 

CI CONTENTION:  The CI elaborated no contention in his 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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  In addition, the CI was notified by the Army that his case may eligible for review of the military disability evaluation of any mental health (MH) condition IAW the Secretary of Defense (SecDef) directive for a comprehensive review of cases referred to a disability evaluation process between 11 September 2001 and 30 April 2012 in which MH diagnoses were changed or eliminated.  Since the CI responded to this mailing, it is presumed that he elected review of the MH condition though he did not specifically contend for it.  Per the SecDef directive, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of the MH diagnoses IAW VASRD §4.129 and §4.130.  The Service rating for the unfitting right knee and elbow conditions and any MH conditions are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Army Board for Correction of Military Records.

RATING COMPARISON:

Service PEB – Dated 20050218	VA - (7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain…	5003	10%	Right Knee Traumatic Osteoarthritis	5010	10%	20051020	
Right Elbow Pain…	5099-5003	---%	Right Elbow Traumatic Osteoarthritis	5010	10%		
Mental Health Condition	Not Considered	Post-Traumatic Stress Disorder	6100	NSC	STR	
No Additional MEB/PEB Entries in Scope	Other x 6 Not In Scope	20051020	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20060330 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY: 

Right Knee Condition.  The Service treatment record (STR) documents a 1985 injury when the CI fell while running and struck his right knee on a rock.  He recalled an associated possible hairline fracture of his patella (kneecap).  On 8 December 1997, the CI fell on a tactical vehicle in Bosnia and sustained an unspecified knee injury.  The X-ray reported probable degenerative joint disease (DJD), that existed prior to deployment, which was further aggravated by the fall.  The diagnosis was listed as probable DJD aggravated by injury.  In the 18 October 2004 (five months pre-separation) MEB narrative summary (NARSUM) by a family medicine physician, the CI complained of chronic right knee pain and stiffness that began in April 2004.  While performing convoys in Iraq, he related multiple instances where they came under attack and had to stop suddenly or take evasive action.  This resulted in him being thrown forward striking his right knee against the dashboard.  He complained of progressive worsening of symptoms following serial traumas to knee.  The CI reported constant aching and throbbing right knee pain.  Pain was exacerbated by cloudy and rainy weather, and somewhat relieved with anti-inflammatory medications.  A right knee X-ray showed marked DJD.  Physical exam showed no ligamentous laxity, a mild to moderate knee effusion (fluid collection), and crepitus (a grating sound or sensation) with motion.  There was tenderness at the superior, medial, and lateral margins of the patella.  Patellar grind test (assesses abnormal patellar movement and painful crepitation) was positive.  Right knee active range of motion (ROM) measured with a goniometer showed flexion to 100 degrees with pain.  Although no specific comment was made on the gait, the examiner noted that the remainder of the physical exam was unremarkable.  The diagnosis was listed as right knee pain and stiffness with osteoarthritis (OA) documented on X-ray.  The 20 October 2005 (seven months post-separation) VA compensation and pension (C&P) exam documented the 1985 right knee injury, but recorded no subsequent injuries.  The CI complained of constant symptoms requiring pain medications.  He reported difficulty with repetitive squatting and kneeling.  He could perform routine daily activities, but symptoms affected his ability to perform his normal work of finishing hardwood floors.  Physical exam showed a normal posture with an abnormal limping gait.  Right knee exam showed an effusion and crepitus but no ankylosis (joint stiffening or immobility).  Right knee active ROM showed flexion to 90 degrees with pain.  There was associated pain, fatigue, and lack of endurance, but no weakness or incoordination.  Drawer test (assesses integrity of anterior and posterior cruciate ligaments) and McMurray test (assesses integrity of menisci) were negative.  The 20 October 2005 right knee X-ray showed advanced degenerative changes.  The diagnosis was listed as post-traumatic severe tricompartmental OA of the right knee. 

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

DOS 20050316
Right Knee ROM
(Degrees)	MEB ~ 5 Mo. Pre-Sep
(20041018)	VA C&P ~7 Mo. Post-Sep
(20051020)	
Flexion (140 Normal)	100	90 (70 with repetition)	
Extension (0 Normal)	Not recorded	0	
Comment	Goniometer	Goniometer not specified	
§4.71a Rating	0%	0%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% (VASRD code 5003; degenerative arthritis) citing ROM.  The VA also rated the knee condition 10% (5099-5010; rating by analogy-traumatic arthritis) citing painful motion.  The limitation of motion documented did not attain a minimum rating under 5260 (leg, limitation of flexion of) or 5261 (leg, limitation of extension of).  There was no additional disability for consideration under 5258 (dislocated meniscus with frequent episodes of locking), 5257 (recurrent subluxation or instability), or 5256 (knee, ankylosis of).  Board members agreed that there was sufficient evidence of pain with use prior to separation, as well objective exam and imaging findings, to support a 10% rating considering functional loss and painful motion (§4.40, §4.59).  The facts support a 10% rating under 5003 for degenerative arthritis selected by the PEB or 5010 for traumatic arthritis selected by the VA.  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 right knee condition.

Right Elbow Condition.  In the 18 October 2004 MEB NARSUM the CI reported chronic right elbow pain and stiffness that began in April 2004, three months after activation and five months prior to entry into the MEB process.  While performing convoys in Iraq, the CI assumed a “personnel protective posture” with his weapon aimed out the vehicle window.  On multiple instances during attacks and evasive actions, he was thrown forward with his right elbow striking the window frame.  The serial traumas in April and June 2004 caused progressive worsening of constant, aching, and throbbing right elbow pain.  The right elbow X-ray showed marked DJD.  The physical exam of the right forearm showed some mild hyperostosis (abnormal bony overgrowth) and tenderness of the proximal ulna.  There was a significant contracture preventing full extension of the elbow.  The ROM with pronation or supination was normal and pain free.  Right elbow active ROM measured with a goniometer showed average flexion to 126 and extension to 25 degrees of flexion.  The remainder of the physical exam was unremarkable.  The diagnosis was listed as right elbow pain and stiffness with radiological evident OA.  At the 20 October 2005 VA C&P exam the CI indicated that he stuck and reinjured his right elbow repeatedly during convoy operations.  He reported that he was limited by his injury in that he could not lift over 20-30 pounds, could not straighten his right elbow, and had trouble buttoning buttons.  He could perform routine daily activities but symptoms affected his normal work of finishing hardwood floors.  The right elbow exam showed no ankylosis but demonstrated significantly decreased ROM.  Active ROM showed flexion to 110 degrees and extension limited to 30 degrees from full extension with pain.  There was associated pain, fatigue, weakness, and lack of endurance, but no incoordination.  The right elbow X-ray was documented as grossly abnormal.  The diagnosis was listed as posttraumatic severe OA of the right elbow with painful decreased range of motion.

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

DOS 20050316
Right Elbow ROM
(Degrees)	MEB ~5 Mo. Pre-Sep
(20041018)	VA C&P ~7 Mo. Post-Sep
(2001020)	
Flexion (145 Normal)	126	110	
Extension (0)	-25 *	-30 *	
Comment	Goniometer	Goniometer not specified	
§4.71a Rating	0%	0%	
(* extension to minus 25/30 degrees (or lacks 25/30 degrees of extension)

The Board directed its attention to its rating recommendation based on the above evidence.  The right elbow condition was implicated in the permanent physical profile, commander’s statement, MEB, and PEB.  The PEB did not rate the right elbow condition (VASRD code 5099-5003; rating by analogy-degenerative arthritis).  The VA rated the elbow condition 10% (5010; traumatic arthritis) citing painful motion.  The CI's description of the injury was deemed insufficient to have caused hyperostosis and contracture in the short time period specified.  The PEB found there was compelling evidence to support a finding that the condition existed prior to service (EPTS) and was not permanently aggravated beyond natural progression by such service.  The Board reviewed the records in evidence and found no line of duty determination regarding the elbow prior to the NARSUM determination and found no records of prior injury while in military status.  The NARSUM examiner apparently based the line of duty yes determination on the history provided by the CI as no other evidence to support this determination was found in the records available for review.  The CI was injured in April and June, five and three months prior to entry into the MEB process.  The action officer opined that the short time interval between the deployment injuries reported by the CI and the level of degeneration evidenced on X-ray exam was insufficient to account for the severity seen.  Board members agreed that there was sufficient evidence that the right elbow condition qualified as EPTS and was not permanently aggravated beyond natural progression by service.  The Board also observed that even if permanent aggravation were conceded, the level of degeneration present would support a 10% rating deduction resulting in a 0% rating which provides no advantage to the CI.  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 right elbow condition.

Contended Mental Health Condition.  The Board considered the MH condition regarding appropriateness of changes in diagnoses and fitness determination in accordance with the special MH review project.  The STR documents a history of depression.  In the 10 September 2004 medical exam review of systems questionnaire, the CI answered “YES” to frequent trouble sleeping.  He answered “NO” to have you ever had or do you now have depression or excessive worry or been evaluated or treated for a mental condition.  In the comments section under on-going issues, the examiner listed depression from deployment incidents in Iraq.  The examiner documented that the CI denied suicidal or homicidal ideation.  He reported the CI was followed by behavioral health as needed and that posttraumatic stress disorder (PTSD) was not appreciated at that time.  The diagnosis listed mild depression.  In the 18 October 2004 MEB NARSUM the CI related some depression and insomnia symptoms.  The physician documented that these symptoms were somewhat related to his deployment experiences, but mostly related to his mother.  The CI reported that during his deployments, his mother experienced a significant physical and mental decline which necessitated her being placed in a nursing home.  The examiner reported this issue seemed to weigh heavily on the CI's mind during the visit.  The exam revealed he was in no acute distress, but he did have a flat affect.  The CI was intermittently tearful, especially while discussing his mother's situation.  The assessment did not list any MH diagnosis.  The 22 July 2005 annual history and physical exam noted right knee and elbow pain complaints in the history of present illness.  The psychiatric review of systems documented no depression or anxiety.  The Iraq/Afghanistan post-deployment screening for PTSD was documented as negative.  The two question depression screen was positive. The examiner noted that an additional assessment of the CI’s positive screen for depression indicated that the patient did not meet criteria for major depressive disorder.  The CI had no symptoms that required additional intervention and no MH diagnosis was listed.

The Board directs attention to its recommendation based on the above evidence.  No limitations from psychological symptoms or MH diagnoses were implicated in the permanent profile, commander’s statement, MEB, or PEB.  The medical encounters addressing psychological symptoms did not document a MH condition that caused performance limitations, was medically disqualifying, or failed to meet retention standards.  Since no MH diagnosis was changed or eliminated during DES processing, the case does not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The MEB NARSUM and VA C&P exams documented minimal or no symptoms and no impairment.  The profile was S1, the commander commented only on the physical condition, and the MEB did not consider a MH condition.  The Board determined that there was no performance based evidence from the record that any MH 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 addition of PTSD or any MH condition as unfitting for rating.

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 DoDI 1332.39 for rating the right elbow condition was operant in this case and the condition was adjudicated independently of that policy / instruction by the Board.  In the matter of the right knee condition and right elbow condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the implied contended mental health condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends no recharacterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130506, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	           

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150006273 (PD201300258)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA