RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01924
BRANCH OF SERVICE:  Army	BOARD DATE:  20150226
SEPARATION DATE:  20050915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Cavalry Scout) medically separated for chronic left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The condition characterized as “chronic left knee pain” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated chronic left knee pain 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:  “My knee conditions were not rated properly.  My exit medical paperwork stated several problems with both knees that were not rated.  Also, I was put in a mental hospital a few months before my discharge and diagnosed with several mental issues from major depression, insomnia, anxiety and loss of appetite.  This was never rated or considered by the Army.  I was just rated for knee and two knee surgeries.  Please look at my exit exam, both knees were completely messed up at the age of 20, no more sports for me and they didn’t rate the mental status, major depression, insomnia, suicidal thoughts, homicidal thoughts and anxiety.  Also, the last time I tore my MCL I just got off profile my SGT (name redacted) made me run the Yarborough Mile at Fort. Polk; during the run I tore my MCL again and partial ACL tear.  After that I was medically boarded.  I had two scopes of the knee, the last scope re-tore my knee and 800cc of pure blood was drained out of my knee.  After that I was kicked out.  I didn’t want to get out, but they told me due to my knees I couldn’t be a Cavalry Scout.  I told my Sargent I wasn’t ready for it and exactly what I said would happen did happen and now I’m messed up.  I didn’t go to the desert, I asked to go but I was on crutches.  During my military time my head got messed up even though I didn’t go to the desert.”

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:

IPEB – Dated 20050810	VA* -  Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain…	5099-5003	20%	Osteoarthritis, Left Knee, Status Post Two Arthroscopic Surgeries	5010	10%	STR	
Other x 0 (Not In Scope)	Other x 1 	
RATING:  20%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20060628 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Chronic Left Knee Pain Condition.  The narrative summary (NARSUM) and record documented the CI had onset of left knee pain in January 2004 while doing PT.  He subsequently underwent two left knee arthroscopic surgeries (March and August 2004) including lateral and medial meniscal repairs, limited synovectomy (partial removal of joint capsule) and partial chondroplasty (bone reshaping) of the femoral condyle.  Surgical findings included a “severe partial tear involving the anterior cruciate ligament [ACL]” and injury of the medial collateral ligament.  He had bleeding into the left knee (hemarthrosis) with magnetic resonance imaging indicating probable recurrent tear of the remaining meniscus, bone bruising and edema.  The physical therapy records documented numerous left knee range-of-motion (ROM) tests with normal extension and painful flexion greater than 90 degrees (normal 140) in the year prior to separation.  Orthopedic examination(s) had documented no post-surgical instability of any of the left knee ligaments.

At the time of the NARSUM, dated 30 June 2005 (10 months after surgery and 3 months prior to separation), the CI’s knee pain required narcotic pain medication every other day and he was on anti-inflammatory medication.  The NARSUM (and the MEB history and physical forms [DD Forms 2808 and 2807-1, and DD Form 2697] did indicate complaints of pain, recurrent swelling, two emergency room visits, but did not have any specification of locking or give way symptoms.  Physical therapy ROM testing (on 20 June 2005 as referenced by the NARSUM) documented painful motion of 0-125 degrees (normal 0-140) with pain scale of 7/10.  Examination documented crepitus with an abnormal gait of “gait dependent on right lower extremity, however, normal alignment.”  There was “decreased heel toe walk due to significant left knee pain.”  There was no tenderness to palpation and no muscle atrophy.  Neurovascular testing of the left leg was normal for strength, reflexes, and sensation.  The NARSUM diagnosis was “Chronic left knee pain status post two arthroscopic surgeries” and the record documented prior diagnoses of osteoarthritis and patellar tendonitis (bilateral).

A physician evaluation of the CI’s complaint of right knee pain greater than the left knee was performed a month after separation.  It included an assessment of “quads [thigh muscles] appear to be quite atrophied bilaterally.”  The CI had asked about the possibility of playing college football and the examiner considered that possible following recommended rehabilitation.

The CI missed his initial VA Compensation and Pension (C&P) exam and the VA rated the treatment exam evidence at 10% as cited above.  At the VA C&P exams performed approximately 17 months after separation (three exams in February, May and June 2007), the CI reported bilateral knee pain with motion, with left knee swelling and use of a special brace, and left leg weakness.  He complained of weekly locking episodes of the left knee and repeated effusions.  ROMs were from 0-110 degrees (normal 0-140) with pain on flexion at 45 degrees.  Following these exams, the VA dual rated the left knee at 10% coded 5010 for osteoarthritis with pain limited motion, and 20% coded 5257 for instability and meniscal surgery residuals.  Later VA evidence indicated that the CI had reinjured his left knee in motor vehicle accidents in 2006 and in June 2007 where he struck his knee against the dashboard.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB’s 20% 5099-5003 rating was based on the USAPDA pain policy.  The VA initial 10% rating was based on the treatment record with a later increase based on exam over a year after separation and following repeated knee injury.  There were no incapacitating episodes attributable to the knee to warrant a 20% rating under VASRD criteria for code 5003.  However, the CI had meniscal surgery and post-operative meniscal injury with frequent effusions and subjective symptoms of locking to warrant a 20% rating under code 5258 (Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint).  Painful motion was noted in the preponderance of the exams in record, however, pain with motion and pain-limited motion are considered under code 5258 and a higher evaluation of 30% (under 5260 or 5261) is not warranted because the evidence did not demonstrate leg flexion limited to 15 degrees or, extension limited to 20 degrees.

There was no objective evidence of instability (ligament laxity) proximate to separation to support coding under instability coding of 5257 (Knee, other impairment of: Recurrent subluxation or lateral instability) and therefore no pathway to either dual rating of the knee or a disability rating higher than 20%.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating level of 20% for the left knee condition was appropriately recommended in this case; however, a code change to 5003-5258 is recommended to comply with VASRD-only rating criteria.

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 left knee condition was likely operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB 20% rating level, but a change in rating code to 5003-5258 to comply with VASRD-only rating.  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:

CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain … Multiple Surgeries 	5003-5258	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131027, 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, AR20150011201 (PD201301924)

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 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:

CF: 
(  ) DoD PDBR
(  ) DVA