RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00193
BRANCH OF SERVICE: Army 	                        SEPARATION DATE:  20050607

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Finance Specialist, medically separated for “chronic anterior knee pain,” with a disability rating of 0%.  

CI CONTENTION:  The CI contends for a higher rating for her knee to include PTSD, which was found not unfitting.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20050311	VARD - 20051028	
Condition	Code	Rating	Condition	Code	Rating	Exam	
CHRONIC ANTERIOR KNEE PAIN	5099-5003	0%	RESIDUAL FX OF LEFT TIBIAL PLATEAU	5299-5262	10%	20050806	
PTSD	Not Unfitting	PTSD	9411	10%	20050806	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:  

CHRONIC ANTERIOR KNEE PAIN.  Service treatment records (STR) show the CI reported the sudden onset of left anterior knee pain in 1999.  She received conservative treatment and fell during a march, sustaining a minimally displaced left tibial plateau fracture on 30 March 2004. Imaging showed no evidence of meniscal or tendon injury but there was evidence of mild focal fluid in the medial tibial plateau.  She received non operative treatment with satisfactory healing of the fracture.  She reported persistent anterior knee pain plus pain along the medial tibial plateau.  Physical therapy for 5 months did not result in symptomatic improvement.  Steroid injections over the proximal portion of her tibia did not improve her symptoms.  A diagnosis of patellofemoral syndrome was made in June 2004.  The commander’s statement noted her injury precluded her walking any distances in excess of 50 feet without pain.  She walked with a distinguishable limp and used a cane, had pain with standing (5 minutes), climbing or maneuvering stairs.  The narrative summary (NARSUM) noted the CI used a cane for walking for at least 6 months.  She reported pain was worse with weight bearing activity, especially stair climbing and prolonged sitting.  She reported intermittent effusions with increased activity and was unable to perform any aerobic event on the Army Physical Fitness Test or do any running without significant left anterior knee pain.  Physical examination demonstrated use of a cane, an antalgic gait and favor of the left knee.  There was no fluid in the knee and her ROM was to 130 degrees (normal 140 degrees.)  There was no evidence of instability, laxity, or stiffness.  She was markedly tender over the mediolateral patella and had a positive patellar grind (pain with movement of the patella) with tenderness over the medial and tibial plateaus.  

At the VA Compensation and Pension (C&P) Orthopedics examination performed 2 months after separation, the CI reported her left knee will occasionally swell up and give out but here was no catching or locking sensation.  In terms of overall pain, she rated the left knee the most severe, followed by the right hip, right knee and left ankle and left foot were about equal.  Examination showed her to walk with a slow, antalgic gait, holding a cane in her right hand and wearing an electrical unit.  She also wore a brace on her left knee.  She had full flexion to 140 degrees (normal) and extension to 30 degrees.  There was no evidence of fluid in the knees and both were stable.  She had a positive patellar glide test bilaterally with no crepitus.  She had mild medial joint line tenderness bilaterally, more severe to the left knee.  There was pain when the knees were palpated.  The orthopedic examiner opined she did not have any ligamentous injuries or meniscal tears but did have bilateral patellofemoral syndrome, which should gradually improve with time.  He did not feel she was significantly disabled at the time.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated chronic anterior knee pain 0%, coded analogously to 5003 (degenerative arthritis), while the VA assigned a 10% rating under a combined 5299-5262 code (tibia and fibula, impairment o; with slight knee disability.)  The Board agreed that there was sufficient evidence to warrant a 10% rating for the right knee IAW VASRD §4.59 (painful motion) and §4.40 (functional loss).  Other pathways to a higher rating were considered, but there was no ankylosis or objective instability, no meniscal removal and no limitation of motion sufficient to warrant any rating higher than 10% for 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% for the right knee condition.
 
Contended PEB Conditions. 

Posttraumatic Stress Disorder (PTSD).  The Board’s main charge is to assess the fairness of the PEB’s determination that PTSD was not unfitting.  The STRs noted the CI was deployed to Iraq from May 2002-October 2003.  Her last evaluation report, dated June 2004, rated her 1 - Successful and 1 - Superior, noting she should be promoted ahead of peers and was a supremely skilled officer.  The Psychiatric addendum, dated January 2005, noted the CI was undergoing a Medical Evaluation Board, primarily for a knee injury.  She reported she had been on many convoys.  She reported bad dreams 2-3 times per week about being surrounded or captured as prisoner of war, 7-8 hours of unrestful sleep, hypervigilance, avoidance of Iraq related stimuli, decreased pleasure in activities, social withdrawal, mild paranoia, irritability and increased startle response.  Mental status examination (MSE) showed occasional distraction, depressed mood, constricted affect, and no suicidal ideation.  She had just become engaged in individual therapy and was to be referred for possible psychotropic medication.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) of 55 (moderate symptoms, impairment.)  Her psychiatric condition was estimated to be not unfitting for military duty at the time.  

An addendum to the psychiatric addendum noted the CI described feelings of horror that another soldier replaced her on a convoy and was shot in the face.  She feared this could have happened to her and this was the source of her PTSD symptoms.  The examiner noted her impairment for further military duty was moderate and impairment for social/industrial adaptability was definite.  

At the August 2005 C&P examination for Mental Disorders, the CI reported nightmares about Iraqi related convoys, hostages, and multiple shootings.  She additionally had flashbacks at times and PTSD symptoms as described.  She was taking two psychotropic medications and was planning to enter a PTSD group.  She had been unable to find work and broke up with her fiancé within the past few months due to her social impairments.  She was distressed that she was running out of funds to pay for the house and was having difficulty finding a job due her chronic left leg pain and PTSD symptoms.  The examiner noted she walked with a crutch and had an electrical unit attached during the interview.  She had a good relationship with her daughter with whom she lived in an apartment.  MSE noted a constricted affect and depressed mood.  A diagnosis of PTSD was rendered with a GAF score of 55 (moderate impairment, symptoms.)  The examiner noted she appeared to over endorse some of her symptoms and she was fixated on achieving funds because she was running out of funds.  She appeared to have mild to moderate social and occupational dysfunction from PTSD symptoms.  The commander’s letter noted the CI was working in her PMOS (technically and tactically.) but was unable to perform any aspects of her duties due to her physical injury.  She otherwise was fully capable and competent and had the knowledge and skills to perform her duties. 

Board members agreed that although the CI experienced various PTSD symptoms, the case file evidence reflected reasonably good duty performance (as related to mental functioning) during the MEB process and separation. Despite the diagnosis and a recommended S4 profile 4 months prior to separation, members concluded that her symptoms of PTSD, although mildly troublesome, did not appear to significantly impact her social and occupational functioning; and thus the PTSD condition was found to be not unfitting.   After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the PTSD contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the chronic anterior left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended PTSD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Left Anterior Knee Pain	5299-5003	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131129, 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 XXXXXXXXXXXXXXXXXX, AR20160008268 (PD201400193)

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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization 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