RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD1300497
BRANCH OF SERVICE:  Army	BOARD DATE:  20131017
SEPARATION DATE:  20070507

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (15D/Aviation Power Train Mechanic) medically separated for a left ankle injury and left knee pain condition.  The applicant began to have left ankle pain while in Basic Training.  He was seen by orthopedics and diagnosed with a large osteochondrial defect of the medial talus, which required an osteochondral autograft transfer system (OATS) surgery.  During the surgical procedure on his left ankle the cartilage plug was removed from the left knee.  His ankle pain improved mildly after surgery but the CI began to experience pain in his left knee.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB conditions of left ankle medial talar dome osteochondritis dissecans lesion, and left knee trochlear chondral defect secondary to OATS procedure were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated the left ankle injury and left knee pain conditions as unfitting rated 10% and 0% respectively, citing the US Army Physical Disability Agency (USAPDA) pain policy for the left knee.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I was only rated for 2 conditions.  No rating was given for left knee, left wrist or mental state.”

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.  The rating for the unfitting left ankle and left knee and conditions are addressed below.  The requested mental health condition is likewise addressed below as part of the Mental Health Review (MHR) project.  The requested left wrist condition was not identified by the PEB, and thus is not 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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20070122	VA - - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Injury	5003-5271	10%	L/Ankle Osteochrondritis S/P OATS Surgery	5271	0%*	*STR	
Left Knee Pain	5099-5003	0%	L/Knee Trochlear Defect Secondary to OATS	5260	0%*	*STR	
No Additional MEB/PEB Entries	Other x 1		
Combined:  10%	Combined:  0%	
Derived from VA Rating Decision (VARD) dated 20071009 (most proximate to date of separation [DOS]).
*CI Failed to report for VA General Exam on 20070621 but VARD dated 20101006 increases L/Ankle to 10% eff 20091028.

ANALYSIS SUMMARY:

Left Ankle Injury Condition.  The MEB narrative summary (NARSUM) dated 3 November 2006, (4 months prior to separation), states that the CI had a left ankle injury while in basic training.  He was evaluated by orthopedics and diagnosed with a large osteochondral defect of the medial talus.  He had an OATS graft from the left knee to the left ankle on 12 November 2002.  He developed worsening pain of the ankle and knee after the surgery.  He had left ankle hardware removal and synovectomy on 22 April 2004, and chondromalacia was noted.  He had pain with standing and sitting, no swelling, predominantly retropatellar at the knee and pain of his ankle.  He reported pain of the left ankle and left knee when lifting heavy toolboxes (75-100 pounds), and climbing on and off aircraft.  X-ray of the left ankle revealed obvious osteochondral defect of the medial talar dome.  The left ankle examination showed tenderness to palpation along the medial malleolus, medial joint line and anterior aspect of the ankle joint, and a well-healed surgical incision about the inner aspect of the left ankle where the medial malleolar osteotomy was performed.  Distal motor and light touch sensation examinations were intact.  The foot and hindfoot alignment were normal.  Ranges-of-motion (ROMs) were flexion 12 degrees (20 is normal) and extension 40 degrees (45 is normal).  There was no VA Compensation and Pension (C&P) examination proximate to the date of separation due to a no-show.

The Board directs attention to its rating recommendation based on the above evidence.  The Board considered the Veterans Affairs Schedule for Rating Disabilities (VASRD) diagnostic codes 5003 (arthritis, degenerative [hypertrophic or osteoarthritis])-5271 (ankle, limited motion of) which the PEB used for a 10% moderate rating, and the VA used code 5271 for a 0% rating.  The Board could not find evidence of a marked degree of limitation of motion, malunion or ankylosis, for a higher rating of 20%.  The Board also considered VASRD §4.10 (functional impairment), §4.40 (functional loss) and §4.59 (painful motion), and could not find evidence in the record for a higher rating.  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 left ankle condition.

Left Knee Pain Condition.  The CI had continuing and worsening left knee pain after the November 2002 OATS surgery in which a graft plug was removed from the knee and grafted to the ankle, as previously described.  X-ray of the knee revealed narrowing of the patellofemoral joint.  On 3 November 2006 (4 months prior to separation), NARSUM knee examination revealed significant pain with patellar compression, normal Q angle, normal patellar tracking, excellent quadriceps tone, no effusion, varus and valgus stable at 0 and 30 degrees, stable anterior and posterior drawer, stable Lachman’s, negative pivot shift and well-healed surgical incision anterior aspect of the left knee.  ROMs were left knee flexion 143 degrees (normal is 140) and extension zero degrees (zero is normal).  There was no VA C&P examination proximate to the date of separation in the record due to a no-show.

The Board directs attention to its rating recommendation based on the above evidence.  The Board considered diagnostic codes 5099 (rated analogous to)–5003 (arthritis, degenerative [hypertrophic or osteoarthritis]), used by the PEB for a 0% rating using the USAPDA pain policy DoDI 1332.39.  The VASRD instructs that when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10% is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003.  The Board also considered code 5260 (leg, limitation of flexion of) which the VA used for a 0% rating.  The Board considered VASRD §4.10 (functional impairment), §4.40 (functional loss), and §4.59 (painful motion).  It is the intention of §4.59 (painful motion) to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.  In this case, 10% for the left knee.  The Board also considered VASRD codes 5256 (knee, ankylosis of), 5257 (knee, other impairment of) and 5261 (leg, limitation of extension of) and did not find evidence for a higher adjudication using alternate coding.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition.

Contended Mental Health Condition.  The Board’s first charge with respect to this condition is an assessment of the fitness based on a preponderance of evidence.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  On the MEB physical exam, DD Form 2807-1, prepared on 29 August 2006, the CI reported he was hospitalized on 19 August 2006 (7 months prior to separation) for anxiety.  The examiner remarked the CI was in group therapy for anxiety and took trazodone for insomnia.  A psychiatry clinic group therapy note 3 months later, on 17 November 2006 (4 months prior to separation), assessed the current diagnosis as adjustment disorder with disturbance of emotions and conduct.  Psychiatric medications listed were fluoxetine (Prozac) 20mg qd, eszopiclone (Lunesta) 2mg tab.  The CI expressed frustration wanting his children back that were removed from the home for almost 2 years.  Prior MH diagnoses on the problems list on the visit were a partner relational problem, nicotine dependence, anxiety disorder not otherwise specified and antisocial personality disorder.  Objective findings were: well-dressed, well-groomed, alert and oriented times four, walking with a cane, good eye contact, normal speech, flat affect, appropriate thought content, linear thought process, logical and goal oriented, denied suicidal or homicidal ideation; good cognition, insight and judgment.  All MH conditions were reviewed by the action officer and considered by the Board.  No MH conditions were specifically profiled, none were referred to the MEB or PEB, none were implicated in the commander’s statement and no MH diagnoses were changed during the Disability Evaluation System (DES) process.  Therefore, the CI did not appear to meet the inclusion criteria of the MHR Terms of Reference.   After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a determination of unfit for the MH conditions; therefore, no additional disability ratings can be recommended.

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 left knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITIONS	VASRD CODE	RATING	
Left Knee Pain 	5099-5003	10%	
Left Ankle Injury 	5003-5271	10%	
	COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130510, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SFMR-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 XXXXXXXXXXXXXXXXXXXXX, AR20140005226 (PD201300497)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl