RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00330
BRANCH OF SERVICE:  Army	BOARD DATE:  20141126
SEPARATION DATE:  20060614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (11C/Indirect Fire Infantryman) medically separated for right knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but could perform a modified fitness exam.  He was issued a permanent L3 and referred for a Medical Evaluation Board (MEB).  The right knee condition characterized as “right knee anterior cruciate ligament (ACL) reconstruction with hamstring autograft,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “continued right knee pain and functional instability” as unfitting, rated at 20%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I have consistently had knee pain & have been told by the VA doctors that there’s nothing they can do, in relation to having them fix & or help the pain.  They have also told me that, due to surgery, I now have arthritis that I will have to deal with from now on.  Additionally, since the surgery, right knee, I have constant pain in my left knee due to putting more weight and pressure on it.  I am on daily painkillers & am contemplating knee replacement surgery in the future.”

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 right knee condition is addressed below.  The requested arthritis and left knee conditions were not identified by the PEB, and thus are not 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 20060124	VA - (~5 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain and Functional Instability, S/P Right Knee ACL Reconstruction, with Hamstring Autograft,
Lachman II-A	5257	20%	S/P Right ACL Surgery	5260	10%	20061120	
Other x 0  (Not in Scope)	Other x 2	20061120	
Combined:  20%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20061207 (most proximate to date of separation)

ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment and worsening severity with which his service-incurred condition continues to burden him.  It is a fact, however, that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  This role and authority is granted by Congress to the Department of Veterans Affairs (DVA).  The Board utilizes DVA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation.  Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Right Knee Condition.  On 20 March 2005 the CI originally fell from training equipment and sustained a twisting type injury, with immediate swelling, to his right knee.  Radiology test revealed a torn ACL which was surgically addressed on 17 July 2005 after a period of rest and immobilization.  Despite physical therapy (PT), he continued with right knee pain and was referred for an MEB.  

At the narrative summary examination on 9 December 2005 (6 months prior to separation), the CI reported right knee pain that was associated with any twisting or pivoting motion or with prolonged running.  He additionally endorsed a feeling of instability described as a “functional instability.”  The physical examination (PE) revealed tenderness and decreased range-of-motion (ROM).  Significant instability was not elicited as there was “…very minimal pivot glide on exam.”  (Lachman II-A = 5-10 mm of translation with a firm endpoint).  There was no comment regarding painful motion, locking, subluxation, atrophy or the presence of an effusion.  His pain intensity was described as “slight” and “occasional.”  His diagnosis remained right knee ACL reconstruction with continued pain and functional instability.  The commander’s statement indicated that the CI’s limitations did not prevent him from performing critical duties as a Soldier.  

At the VA Compensation and Pension examination on 20 November 2006 (performed 5 months after separation), the CI reported a constant, aching, 8/10 right knee pain that was aggravated with activity and relieved with rest.  The examiner stated, “At the time of pain [the CI] can function without medication. He states his condition does not cause incapacitation.”  The PE revealed tenderness and painful limited motion.  All cartilaginous and ligament instability tests were normal.  The examiner noted, “There is no functional impairment resulting from the [right knee] condition.”  His diagnosis was post-surgical ACL with scar.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.
DOS 20060614
Right Knee ROM
(Degrees)	MEB ~ 7 Mo. Pre-Sep
(20051209) 	VA C&P ~ 5 Mo. Post-Sep
(20061120) 	
Flexion (140 Normal)	120	110	
Extension (0 Normal)	0	0	
Comment	tenderness	painful motion; 
tenderness	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under code 5257 (knee; other impairment) citing post-surgical intervention with minimal instability upon physical testing.  The VA assigned a 10% rating under code 5260 (leg; limitation of flexion) citing limited painful motion.  In light of non-compensable ROM, Board members considered and agreed that the PEB’s 20% rating under code 5257 was presumably due to the Lachman’s instability test listed as II-A…equating to “moderate” impairment.  The Lachman maneuver is a test to assess the amount of anterior tibial translation (ATT) there is within the knee in evaluating the integrity of the ACL.  The action officer noted that the Lachman grading levels include I, II, and III corresponding to <5 mm, 5-10mm, and >10 mm of anterior translation and subset “A” or “B” for having a “firm” or “no endpoint,” respectively.  Medical literature has documented that a degree of ATT (approx. 5-7 mm) can be normal.  Board members agreed that the degree of instability in this case and noted on the prior to separation examination was not supported at a rating higher that the PEBs 20%; this was additionally supported in the post-separation examination where no instability was in evidence.  Absent compensable ROM or abnormal boney union about the knee, the Board agreed that the PEB’s single rating coded as code 5257 was most appropriate and beneficial to the CI.  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 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.  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 right 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 20140111, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150007085 (PD201400330)

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