RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01417
BRANCH OF SERVICE:  Army	BOARD DATE:  20150114
SEPARATION DATE:  20040702  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Accounting Specialist) medically separated for chronic pain, left knee.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The chronic left knee pain condition, characterized as “left knee pain and instability” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic pain, left knee” as unfitting, rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Have had continued pain, medication, injections, and recent surgery.  Have lossed range of motion.  Was not separated for migraines.”  [sic]

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20040322	VA - (3 Years 1 Month Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee …	5099-5003	0%	Status Post ACL Repair: Degenerative Changes Left Knee	5010	10%	20070802	
Other x 0 (Not in Scope)	Other x 2 (Not in Scope)		
Combined:  0%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20070919 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Pain, Left Knee Condition.  The narrative summary (NARSUM) noted that the CI tore the anterior cruciate ligament of her left knee while running the physical fitness test in 2001.  During repair, the operative report identified Grade 1 chondromalacia (arthritis) with synovitis, and normal medial and lateral menisci.  Despite rehabilitation, the CI continued to have knee pain and effusions (swelling in the joint).  At the MEB exam, the CI reported intermittent to frequent pain, edema, effusions, and the occasional feeling of instability.  The NARSUM exam noted that the knee had full range-of-motion (ROM) (normal 0-140 degrees), moderate effusion, with laxity of the lateral collateral ligament (instability test), pain on anterior Lachman (instability test), and pain medially with a “clunk on extension” on valgus stress.  There was no instability on the Lachman or anterior drawer tests.  McMurray examination (meniscal sign) was negative.  At the VA Compensation and Pension exam performed 3 years after separation, the CI reported that her “knee swells constantly and never goes down,” she continues to use a brace and that her knee pain interferes with her activities of daily living and her job.  The examiner noted that her gait was steady and smooth, “Left quadriceps muscle 44.5 cm.  Right quadriceps 48 cm.  Loss of normal curvature.  Suprapatella, medial and lateral tenderness to palpation.  Crepitus.  No increased heat or redness.  No edema.  Moderate effusion.  Extension  0 degrees.  Flexion 0-90 degrees with pain at 90 degrees.  Pain with ROM.  Repetition of three produced increased pain, weakness, lack of endurance, fatigue and in coordination with flexion to 90 degrees with no additional loss of range of motion than noted.  Knee stable.”  Later VA records indicated knee surgery (2012) and additional VA rating for instability effective 2008 and increased in 2009.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left knee pain at 0% under 5099-5003 (arthritis degenerative).  Three years remote from separation, the VA rated the knee at 10% under 5010 (traumatic arthritis).  The VA exam was too remote to have a high probative value, and the MEB exam was used for the Board’s rating determination.  The service treatment record did not document any compensable ROM impairment under the specific knee codes; however, there was objective evidence of painful motion and effusions to warrant a 10% rating IAW VASRD §4.59 (painful motion) under 5099-5003.  There was no meniscal pathology for any rating under 5258 or 5259 (cartilage, semilunar).

The Board considered if there were sufficient evidence of knee instability for dual coding of the knee, or a higher rating under code 5257 (Knee, other impairment).  The NARSUM exam documented lateral ligament laxity, the CI had symptoms of instability and the NARSUM and MEB diagnosis included knee instability.  The Board therefore determined that dual (additional) rating with a 10% (“slight”) rating coded 5257 was warranted.  There was insufficient evidence that instability rose to the “moderate” 20% level of disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommended dual rating of the knee with a disability rating of 10% coded 5099-5003, and an additional 10% rating coded 5099-5257 (knee other impairment).

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 chronic left knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic left knee pain condition, the Board majority recommends dual rating of the knee with a disability rating of 10% under 5099-5003, and an additional 10% rating coded 5099-5257, both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

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

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Pain, Left Knee	5099-5003	10%	
	5099-5257	10%	
COMBINED 	20%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20130916, 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, AR20150007854 (PD201301417)

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						

CF: 
(  ) DoD PDBR
(  ) DVA