RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00344
BRANCH OF SERVICE:  Army	BOARD DATE:  20150220
SEPARATION DATE:  20060405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Military Policeman) medically separated for left knee pain.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “left knee pain after arthroscopy for anterior medical meniscus tear debridement as well as medical plica and synovectomy,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the left knee condition as unfitting, rated 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Due to the multiple corrective surgeries on left knee and several knee braces later over compensation transfer to right knee.  Left knee continues to give out and unable to stand for long periods of time or walk for distance.  I am unable to perform most normal job duties for prolonged periods of time.  I am also affected by cold weather conditions and rain, snow, sleet, and ice.  I have now had issues with my right knee for pain due to extent strane [sic] from pain from L knee.  I was issued knee brace for right knee fails to work as well.  I am finding it difficult to maintain employment due to the physical limitations that I now have and no longer have the same range of motion I had before.  I am now in constant pain in the left knee where it locks up and have a difficult time bending it.”

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 20060221	VA - (7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain Status Post Arthroscopy	5099-5003	10%	Left Knee Degenerative Arthritis Status Post Arthroscopy	5010	10%	20061102	
Other x 0 (Not in Scope)	Other x 1	20061102	
Rating:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20060810.

ANALYSIS SUMMARY:

Left Knee Condition.  A clinic note dated 12 April 2004 indicated the CI had left knee pain for 3 weeks after doing knee benders during training.  Physical therapy (PT) was initially carried out but it was unsuccessful.  A posterior horn lateral meniscus (cartilage of the knee) tear and degeneration of the medial meniscus were noted on a magnetic resonance imaging dated 28 October 2004.  An orthopedic evaluation on 16 November 2004 revealed tenderness on palpation of the lateral joint line of the knee and pain on motion, while an evaluation on 1 December 2004 documented pin point lateral joint line tenderness, a positive patella grind test (to check for knee cap abnormality), and a positive McMurray’s test (to check for meniscal involvement).  Arthroscopic surgery was carried out on 27 January 2005 for persistent pain despite conservative treatment including medications, PT, and modifications of activities.  Surgery revealed a medial meniscus tear, impinging synovial plica (the protective joint capsule), and hypertrophic synovium (excess membrane tissue lining the joint space).  The meniscus tear was debrided as were the other two aforementioned conditions.  Post-operative healing was uneventful, but pain persisted in spite of PT.  However the CI resumed running up to 3 times a week between 4 to 6 miles and noted pain increased tremendously.  By 2 November 2005, he had a full range-of-motion (ROM) of the left knee.  But pain persisted especially in the infrapatellar (below the knee) area and medially.  The CI reported his leg went numb when he sat for more than 3 minutes at 90 degrees; his knee clicked and popped with the ROM; it swelled with activity; it locked, which required him to pop it to get it moving; and he had one episode of the knee giving way.  Orthopedic examination on 29 November 2005 revealed decreased sensation of left lateral thigh and calf, normal motor strength, a large palpable tibial tubercle bump (below the knee cap; in front of the leg), no effusion (fluid in the joint); ROM 0 degrees-135 degrees, no laxity or meniscal involvement, a positive patellar grind, and positive tenderness to palpation (TTP) (above the knee cap) at the proximal patellar tendon.  Pain continued and was considered patellar tendonitis (inflammation of the knee cap tendon(s) and RPPS (retropatellar pain syndrome) (pain below the knee cap).  A new nonsteroidal anti-inflammatory medication was prescribed; a new knee brace was issued; and the CI underwent four iontophoresis (electrical stimulation) treatments.  Because of the continued pain and lack of progress, the CI desired to proceed with a Medical Evaluation Board (MEB) on 9 December 2005.

The MEB narrative summary dated 9 February 2006 noted the CI injured his left knee during training in June 2004.  While on duty, he further injured it while chasing and apprehending a “subject” at which time his knee popped.  He subsequently underwent arthroscopy with debridement of the medial meniscus tear and medial plica (portion of the joint capsule) and a synovectomy (removal of joint membrane).  Pain continued in spite of treatment and was associated with frequent popping and clicking of the knee.  Examination revealed no effusion and a ROM of 0 degrees-135 degrees.  There was no laxity or meniscal tenderness, but there was exquisite TTP at the inferior pole of the patella (lower part of the knee cap) with a 1.5 x 1.5 x 1 cm slightly mobile mass located where the patellar tendon inserts into the tibial tubercle.  Patellar grind testing was negative and there was mild TTP along the medial joint line.  The CI could not stand for long periods of time and had difficulty kneeling, squatting, performing long distance running, doing road marching or jumping.  The pain intensity was slight and the pain frequency was constant.  A permanent L3 profile was issued on 21 December 2005 with limitations of no running, jumping, hopping, deep knee bending or squats, marching or rucking.  The commander’s statement dated 14 February 2006 indicated his physical impairments prevent him from fulfilling the requirements of a Military Police; and he was unable to take the physical fitness test due to profile restrictions.  The MEB examination dated 9 January 2006 was performed concurrently with a VA Compensation and Pension (C&P) examination dated 12 January 2006, performed 3 months prior to separation, indicated the CI injured his knee at basic training in 2005 and reinjured it while attempting to chase a suspect in a criminal investigation.  Examination demonstrated a full ROM with flexion to 140 degrees and extension of 0 degrees.  Muscle strength was normal and there was no swelling, joint effusion or tenderness of the knees or any symptoms or loss of motion following repetitive motion.  There was TTP and pain at the at the distal patellar ligament.

At a VA C&P examination on 2 November 2006, 7 months after separation, the CI reported he injured his left knee after a fall while in pursuit of a “subject.”  The torn meniscus was repaired in January 2005.  He reported that he had intermittent knee pain that occurred with a change of weather or if he sat or stood too long.  He took Aleve (a nonsteroidal anti-inflammatory medication), used a knee brace for day activities and a cane for ambulation, and had a moderate antalgic gait. Flexion was 0 degrees-120 degrees with pain at 120 degrees with tenderness along the medial joint line.  There was no laxity, but there was crepitus (grinding) and a positive McMurray’s test (to determine a meniscus tear) with apprehension and pain.  Pain was noted during the ROM, but there was no additional limitation of motion.  Left knee X-rays were normal and the diagnosis of a meniscal tear status post surgical repair with chronic left knee strain was made.  A year after separation, according to an orthopedic note dated 3 April 2007, the CI had no pain for 6 months.  Examination of the knees revealed a full ROM and was otherwise unremarkable except for a prominent left tibial tubercle more so than the right.  X-rays of both knees reported to be on 5 March 2007, but the date stamped 5 April 2007 showed no significant degenerative changes, but was noted to have bilateral “nonunions” of the tibial tubercles suggestive of Osgood-Schlatter disease, (childhood condition of painful knees), which necessitated obtaining a waiver for the CI, who was attempting to enter the ARNG (Army National Guard).  However, the Military Entrance Processing Station (MEPS) examiner did note “Normal functioning knees with no significant degenerative disease.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using 5099-5003 for left knee pain status post surgery with a full ROM, not requiring narcotics, described as slight/constant.  The VA also assigned a 10% rating using code 5010 for left knee degenerative arthritis status post arthroscopy.  By the time of separation, the CI’s condition had improved such that he had a full ROM, albeit that knee pain persisted in spite of treatment.  Because he had a non-compensable ROM, use of the analogous code 5099-5003 is reasonable.  Alternatively, code 5259 (cartilage, semilunar, removal of, symptomatic) likewise affords the CI a 10% rating: however, the Board was unable to find a route to a higher rating using code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint).  While the CI mentioned locking of the knee in 2005, the record is silent on any additional episodes proximate to separation or thereafter; and there was no effusion observed during that time frame either.  Within a year of separation, a MEPS examiner commented on X-rays that showed nonunion of the tibial tuberosities, but added there was normal functioning of the knees.  Code 5262 (tibia and fibula, impairment) offers a rating for nonunion with loose motion requiring a brace.  While there was a tender, mobile nodule where the patella tendon inserts in the tibial tubercle, it was most likely related to old Osgood-Schlatter disease.  Left knee function was not impaired by it, pain was reported to have resolved after separation, and no other prior to separation or after separation imaging reported nonunion of the tibial tuberosities.  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.  As discussed above, PEB reliance on the USAPDA pain policy for rating left knee was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left 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 20140109, 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, AR20150011008 (PD201400344)

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: