RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-01456
BRANCH OF SERVICE:  Army	BOARD DATE:  20140820
SEPARATION DATE:  20040307

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-6 (11B/Infantry) medically separated for a bilateral knee condition; which could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) but could perform an alternate physical fitness test.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral knee condition, characterized as “bilateral knee pain with degenerative joint disease (DJD), status post right anterior cruciate ligament (ACL) reconstruction and left meniscectomy,” was forwarded as the sole submission to the Physical Evaluation Board (PEB) IAW AR 40-501 (judged medically unacceptable).  The Informal PEB adjudicated “bilateral DJD [specifying right and left surgical residuals]” as unfitting, rated 20%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Bilateral Knee Pains”

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 bilateral knee condition is addressed below; and, 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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20031201	VA (4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
DJD, Bilateral Knees...[Surgical Residuals]	5003	20%	Left Knee DJD, post Meniscectomy	5010-5259	10%	20031208	
			Right Knee DJD, post ACL Repair	5010-5260	10%	20031208	
Other x 0 (Not in Scope)	Other x 4 (Including 0% R and L Knee Surgical Scars)	20031208	
Combined:  20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20040310 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Bilateral Knee Condition.  The service treatment record (STR) documents a sports injury of the right knee in 1995, with a diagnosis of a torn ACL which was arthroscopically repaired that same year (patellar tendon graft) and, the surgery also included a partial lateral meniscectomy (removal of damaged cartilage).  Post-operative notes indicate an uneventful recovery and return to duty on an L2 profile.  The STR contains numerous entries referring to mild post-operative ACL laxity (1-2+ Lachman’s, firm end point, negative pivot shift); which is not indicative of significant or functional instability and not an unusual accompaniment of ACL graft surgery (graft more lax than native tendon).  The STR documents another sports injury to the left knee in 2000, which resulted in an arthroscopic lateral meniscectomy in October 2001.  After the second surgery the CI returned to physical therapy, was dispensed bilateral hinged knee braces for various activities, and remained on an L2 profile; but, was unable to resume the rigors of his MOS and did not wish to change his MOS.  Knee radiographs demonstrated mild degenerative changes bilaterally with surgical changes, but normal alignment and no other abnormalities.  There was no STR evidence for either knee of recurrent effusions, signs of cartilage impingement or locking (after meniscectomy), instability (noting the above post-operative ACL laxity of the right knee), or significantly persistent gross range-of-motion (ROM) abnormalities and, there is no documentation of subjective complaints of instability by the CI.  The last two orthopedic entries in the STR prior to PEB proceedings (7 and 5 months pre-separation) corroborate the above STR evidence and document grossly normal ROM of both knees.

The narrative summary (NARSUM) assigned a pain rating of “moderate and frequent” which “may be worsened by heavy lifting, driving, and climbing on vehicles required in his MOS.”  The physical exam documented a “slightly antalgic” gait, bilateral crepitus, “minimal” tenderness of the left knee only, the absence of effusion, 5/5 strength, no signs of cartilage impingement, and stability in all planes to stress testing except for the right ACL findings elaborated above.  Bilateral ROM was documented as “full” with “pain in full flexion.”  The VA Compensation and Pension (C&P) examination (4 months after separation) states, “Of both knees, he reports give away, lockup, fatigability, weakness, lack of endurance and instability.”  No elaboration or examples were provided.  Constant pain in both knees was reported, rated 8/10, with flare-ups precipitated by “weight bearing, bending and standing.”  The VA physical exam documented a “right leg limp,” bilateral joint line tenderness and crepitus, the absence of effusion, negative signs of cartilage impingement and no instability in any plane bilaterally (no comment regarding right ACL laxity).  The VA ROM measurements were 120 degrees flexion (normal 130 degrees; minimum compensable 45 degrees) of the right knee with painful motion, and “full with no pain” flexion of the left knee.

The Board directs attention to its rating recommendation based on the above evidence.  Although the PEB did not elaborate the foundation for its bilateral 20% rating, the pain rating documented in the NARSUM yields a 20% rating IAW the USAPDA pain policy.  It is also possible that the PEB intended a combined rating of 20%, complying with criteria of the VA Schedule for Rating Disabilities (VASRD) for separate joint ratings of 10%.  The Board, furthermore, must consider separate ratings for PEB bilateral joint adjudications IAW VASRD §4.7 (higher of two evaluations); although, separate fitness assessments must justify each disability rating.  Given the impairment and separate surgical interventions for each knee, and the fact that both joints were judged medically unacceptable and both were profiled, members agreed that each knee was reasonably justified as separately unfitting and thus eligible for separate rating.  With regards to separate ratings, the CI’s report of joint locking (per VA C&P) warrants consideration of a 20% rating under code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain and effusion into the joint); but, there is no corroboration of such a symptom in the evidence, nor is there any indication of cartilaginous impingement which might precipitate mechanical locking of the knee.  The Board also deliberated whether the ACL laxity in the left knee and the use of joint braces could justify a recommendation for additional rating for instability; but, members agreed that this finding did not reasonably meet the criterion of instability and, it is further noted that the VA did not confer additional rating for instability.  Although there was a lack of ROM limitation or other criteria for a rating higher than 10% under analogous coding 5003 (degenerative arthritis) or other available joint code, members agreed that a minimum compensable 10% rating for each knee was supported by VASRD §4.59 (painful motion); which was the VA basis for its separate 10% determinations.
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, the PEB may have relied on the USAPDA pain policy for rating and the condition was adjudicated independently of that policy by the Board.  In the matter of the combined bilateral knee condition, the Board unanimously recommends that each joint be separately rated as follows:  an unfitting left knee condition coded 5259 and rated 10%, and an unfitting right knee condition, coded 5010 and rated 10%, 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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Degenerative Arthritis and Residuals of Meniscectomy, Left Knee	5259	10%	
Degenerative Arthritis and Surgical Residuals, Right Knee	5010	10%	
COMBINED (w/ BLF)	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 XXXXXXXXXXXXXXX, AR20150003001 (PD201301456)

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 description without modification of the combined rating or 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