RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00093
BRANCH OF SERVICE:  Army	BOARD DATE:  20141216
SEPARATION DATE:  20080122

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty E-3 (Operating Room Specialist) medically separated for a right knee condition.  This condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards.  The CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The knee condition, characterized as “chondromalacia right knee” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501; no other conditions were submitted by the MEB.  The PEB adjudicated “chondromalacia patella, right knee …” as unfitting, rated 0%, referencing AR 635-40, appendix B-15 and the “table of analogous codes.”  The CI made no appeals and was medically separated.

CI CONTENTION:  “I can barely walk most days from knee pain, which also interferes with sleep & work.  I live with constant 8 on a 1-10 pain scale.”

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 20071128	VA - (7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patella, Right Knee Evaluated as Arthritis …	5099-5003	0%	Degenerative Joint Disease, Right Knee	5003-5260	10%	20080814	
			Residual Scar, S/P Right Knee … 	7804	10%	20080814	
No Additional MEB/PEB Entries in Scope	No Additional VA Entries in Scope	
Combined:  0%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20080905.

ANALYSIS SUMMARY:

Right Knee Condition.  The narrative summary and the service treatment record detailed that the CI had two surgeries on the right knee (for partial tear of the anterior cruciate ligament, medial meniscus tear, chondral [cartilage] tearing of the medial femoral condyle [lateral surface of the knee] and plica debridement) prior to entering service and required a waiver to enlist.  She reinjured the knee in January 2006 (twisting knee on a road march) and subsequently had increased pain and swelling with running – she had noted that “her knee has ‘locked up’ or buckled on several occasions” since entry.  She underwent surgical realignment of her patella (with medial menisectomy) in April 2007 (9 months prior to separation).  The MEB exam 5 months prior to separation noted a healed surgical scar, palpable hardware at the tibia, edema (swelling) generally around the patella, tenderness with palpation, and crepitus (grating) with motion.  No ranges-of-motion (ROMs) were done.

The orthopedic consult 3 months prior to separation (“MEB Consultation”) noted that the CI had no episodes of recurrent instability after her surgery, that she had persistent pain and recurrent effusions in her knee, and that she was unable to return to full duty.  Exam demonstrated a well-healed surgical scar on the knee, positive apprehension and inhibition of her patella, tenderness to palpation over the palpable retained hardware and the lateral aspect of the patellofemoral joint, hypermobility of her patellofemoral joint and trace effusion.  The ROM of the right knee was 0 to 130 degrees (normal 0 to 140 degrees).  She had slight decreased strength (4+/5) with extension of the right knee, some grinding and crepitus of the patellofemoral joint (between the kneecap and the leg), and no evidence of laxity.  The final diagnosis was chondromalacia (softening of the cartilage) of the right knee.

Subsequently, 2 months prior to separation (on the day of the MEB), the CI had a surgery to remove the hardware from her original procedure and 2 weeks after that her sutures were removed.  The CI reported that she had “full ROM,” and the orthopedist noted that she was neurovascularly intact with full ROM.

At the VA Compensation and Pension exam 7 months after separation, the CI complained of stiffness of the right knee, “painful numbness” lateral and distal to the knee (so bad that she could not touch it at times), tenderness directly on the patella and increasing pain that shot/radiated down her leg if she stood too long.  The examiner stated, “She has had no further dislocation of her right knee.”  On exam, the CI was able to extend her knee to 0 degrees (normal) 3 times, but was able to flex her knee only once, to 120 degrees (normal 140 degrees), due to pain.  The CI reported extreme allodynia (pain due to a stimulus which does not normally provoke pain) with any type of touch to her right knee.  The examiner stated, “In regards to the Deluca requirements, there is an additional estimated loss of 20 degrees of flexion of the right knee due to flare-up secondary to pain ….”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition at 0% with code 5099-5003 (Arthritis, degenerative), citing no loss of mechanical motion.  The VA rated the condition at 10% analogous to code 5260 (“limitation of flexion of knee”), based on pain-limited motion.

Most exams proximate to separation (and all exams with formal ROM testing) indicated painful or limited motion of the right knee, and the knee was symptomatic.  Given the CI’s degenerative changes and meniscal surgeries, the Board considered the criteria for 5258 (20% - Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain and effusion into the joint) and 5259 (10% - Cartilage, semilunar, removal of, symptomatic).  There was insufficient evidence of frequent effusions, or locking following surgical repair which would support rating under code 5258.  There was no post-surgical instability for dual rating.  Meniscal rating at 10% analogous to code 5259 includes painful motion and there was no ROM limitation that would warrant higher than a 10% rating.

Any contribution of the scar for decreased motion relating to the knee was considered under the rating of the knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10%, coded 5003-5259 for the right 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.  As discussed above, PEB reliance on AR 635-40 as well as the Table of Analogous Codes for rating the knee condition was operant in this case and the condition was adjudicated independently of these regulations by the Board.  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5003-5259 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends modifying the case determination as follows, effective the date of medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chondromalacia Patella, Right Knee	5003-5259	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, 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, AR20150008495 (PD201400093)

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 10% 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