RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00024
BRANCH OF SERVICE:  Army	BOARD DATE:  20150129
SEPARATION DATE:  20070821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Medical Equipment Repairer) medically separated for a left knee condition.  The left knee 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 left knee condition, characterized by the MEB as “left knee pain and instability, s/p left ACL [anterior cruciate ligament ] reconstruction and partial medial meniscetomy” and “medial and lateral meniscal tears,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left knee ACL insufficiency with 1 plus Lachman” as unfitting, rated 10%, citing application of Department of Defense Instruction (DoDI) 1332.39, para E2.A1.1.15.2.3.  The CI submitted a rebuttal, but subsequently concurred with the Informal PEB findings and was medically separated.

CI CONTENTION:  “In 2004 I had a ACL and torn meniscus repaired.  I was deemed not fit to perform my duties as an 11B Infantryman.  I reclassed to 91A.  During AIT I tore my meniscus again during PT.  In 2007 I was given a military discharge bc of constant tears.  In 2009 I was evaluated by the VA and they told me that my ACL was in the wrong spot.  Apparently that was the standard spot for all ACL surgeries repairs.  5 yr research showed the standard spot was actually wrong.  It provided front and back support but not pivot support causing the meniscus to not hold up and do its job.  I had to undergo the same surgery from 2004 in 2009 changing the spot of the ACL and repairing the meniscal tears.  Recent evaluation show conditions have worsen.  I endure the pain every day of stiff knees even with medication.”

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 20070606	VA - (1.5 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee ACL Insufficiency 	5257	10%	S/P L Anterior Cruciate Ligament and Meniscus Repair w/Slight Instability 	5262	10%	20071010	
			Scar s/p ACL Repair	7804	0%	20071010	
Other x 0 (Not in Scope)	Other x 11	
Rating:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20080220 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Knee Condition.  The narrative summary (NARSUM) notes the CI to have sustained an injury to his left knee during sports activities in May 2003.  A magnetic resonance imaging (MRI) of the left knee revealed a tear of the ACL and of the outside back cartilage of the knee (left posterior lateral meniscal tear).  The CI underwent surgical repair of the ACL tear and revision of the cartilage tear in September 2004.  Examination of the knee after completion of the surgery while still under anesthesia revealed a range-of-motion (ROM) of flexion of 130 degrees, normal extension and no evidence of knee instability (Normal:. 140 degrees/0 degrees).  On physical therapy (PT) evaluation on 4 March 2005, 6 months after surgery, the CI was able to run “up to a mile” without difficulty.  Exam at this time revealed a full ROM of the knee, with no noted instability.  The left upper leg (quadriceps muscle) was decreased in size compared to the right, but motor strengths were equal in both legs.  The examiner opined that this was due to the CI missing some of his PT rehabilitation secondary to emergency leave.  She further noted that the CI would be able to return to a new MOS in 2-to-3 months.  In May 2005, the CI reinjured the left knee when he tripped over a stump, resulting in increasing pain, and swelling.  An examination on 13 March 2006, the CI reported continued pain and swelling, but no episodes of instability or “locking” up of the knee.  A repeat MRI of the left knee in February 2007, revealed a recurrence of the previous tear of the meniscus, but all ligaments, including the ACL repair site, to be intact without injury.  An examination on 27 February 2007, 6 months prior to separation, the CI reported occasional buckling of the knee without “locking.”  On examination, motion of the knee was normal without pain, swelling laxity or instability.  Motor strength and sensory were normal.  An orthopedic evaluation on 3 April 2007, no instability but slight laxity (1A Lachman test) of the knee was reported.  ROM was flexion 140 degrees and extension normal.  The left quadriceps (quad) muscle was noted to be slightly smaller than the right (circumference: L-51 cm; RT- 52 cm).  The CI was able to squat but with inner knee discomfort.  No knee swelling was present.  At the MEB exam on 26 April 2007, 4 months prior to separation, the CI reported continued knee pain during the day but was taking no medication for pain control.  The MEB physical exam noted the CI to “ambulate well.”  Exam of the knee revealed some forward laxity without instability.  “Obvious atrophy of the left” quad muscle was reported (circumference: L 46 cm; Rt 49 cm).  Motor and sensory exams were normal.  ROM results from this exam are summarized below.  At the VA Compensation and Pension exam performed approximately a month after separation, the CI reported “weakness and pain” of the knee but no swelling, dislocation or locking.  The CI was under no treatment for the knee condition at that time.  On physical examination, the gait was normal with a brace.  There was no evidence of muscle loss or functional impairment in the left lower leg. 

The left knee was tender to palpation without swelling.  Slight “instability” of the knee was recorded without evidence of subluxation or locking.  Motor, sensory and reflex exams of the legs were normal.  ROM results from this exam are summarized below.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

Left Knee ROM
(Degrees)	MEB ~ 4 Mo. Pre-Sep
	
PT~3 Mo. Pre-Sep	VA C&P ~ 1.5 Mo. Post-Sep
	
Flexion (140 Normal)	114 with pain	115 with pain	100 with pain	
Extension (0 Normal)	19	0	0	
Comment	
Ambulates well; motor/sensory intact	
Slight laxity; no instability	Gait normal with brace. Slight laxity; no muscle atrophy; motor/sensory/reflexes wnl	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and the VA both rated the knee condition at 10% using different codes.  The PEB rated under code 5257 (subluxation/lateral instability/slight).  A higher rating of 20% under this code requires the condition to be “moderate.”  The VA rated under code 5262 (Tibia Impairment/knee/ slight).  A higher rating under this code requires the condition to be “moderate.”  The Board considered a rating under ROM criteria.  The Board agreed that the condition was not compensable under code 5260 (limitation of flexion).  The Board considered a rating under code 5261 (loss of extension).  The Board noted the report of extension of 19 degrees (normal 0 degrees) on the NARSUM examination, but was unable to ascertain whether this represented an increase or loss of extension.  The Board agreed that the remainder of the record in evidence supported no rating for loss of extension under this code.  The Board agreed the knee condition rose to the level of 10% for painful motion IAW §4.59.  The Board considered a rating under code 5257 (subluxation/lateral instability).  The Board agreed the left knee condition had some forward laxity but no lateral instability/subluxation after surgery, given the normal gaits, and findings on examinations proximate to separation. The Board, therefore, recommended no rating under this code.  The Board noted the reports of slight muscle atrophy related to the post-operative rehabilitation and considered a rating IAW §7.73 (muscle injuries).  The Board agreed that the record supported the condition to be mild and not unfitting per se given the normal motor strength evaluations and lack of functional impact.  The Board recommended no rating under this code.  The Board considered a rating under code 5262 (tibia/knee impairment).  Board consensus was that the condition did not rise to the “moderate” level required for a 20% rating given the normal gaits, lack of swelling, and mild functional derangements.  The Board considered a rating IAW §4.118 (Skin/scars) but was unable to do so as surgical scars were well-heated, not inflamed and not irritated or tender.

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 knee condition.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
XXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXXXXX, AR20150008687 (PD201400024)

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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA