RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxxxxxxxx	CASE:  PD-2014-00347
BRANCH OF SERVICE:  Army	BOARD DATE:  20151103
SEPARATION DATE:  20071214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63B, Light Wheeled Vehicle Mechanic) medically separated for a left knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic left knee pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded seven other conditions (atypical depressive disorder, insomnia, obesity, elevated blood sugar, hypercholesterolemia, elevated blood pressure and gastroesophageal reflux disease) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “chronic left knee pain” as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The IPEB adjudicated the obesity condition as being not compensable, although it may be administratively unfitting.  The remaining conditions were determined to be not unfitting and therefore not ratable.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in her application.  

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:  

IPEB – Dated 20071012	VA* - (~2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Left Knee Osteochondroma	5299-5014	10%	20071010	
Other x 7 (Not In Scope)	Other x 8 	
RATING:  0%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080516 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  

Chronic Left Knee Pain Condition.  A note dated 29 March 2005 in the service treatment record (STR) indicated the CI had left lateral knee pain for 2 weeks and had a bone scan that revealed a stress fracture of the proximal left fibula at the tibial-fibula articulation.  Treatment consisted of Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), a profile, and physical therapy.  An X-ray series of the left knee was negative on 27 April 2005 and an MRI of the left knee performed on 23 June 2005 was normal.  In August 2005 after a run, the CI developed swelling and an increase of symptoms with pain of a severity of 4/10 (10 being the worst pain).  An orthopedic examination of the left knee was normal on 30 August 2005; however the orthopedic surgeon’s evaluation was a bony prominence at the proximal tibia was consistent with an osteochondroma, which was at the same location as the increased uptake on the bone scan.  He opined the CI’s symptoms were from snapping of the iliotibial band (ITB) over the mass.  Arthroscopy of the left knee and an iliotibial fasciotomy (to release tension on the ITB) were performed on 3 October 2005.  Physical therapy resumed postoperatively.  Subsequently, the CI was cleared to deploy, but a P2 profile was issued to reduce running and impact activities.  In January 2006 the CI noticed tenderness of the left knee on ambulation.  Examination revealed minimal tenderness along the scar and the range-of-motion (ROM) of the left knee was 0-130 degrees.  In March 2006 the CI reported her left knee suddenly ‘locked up’ with 6/10 pain after a popping sound was heard.  There was tenderness on palpation at the distal aspect of the scar on the lateral left knee.  Piroxicam, an NSAID, was prescribed along with stretches, heat and ice.  In July 2007 examination revealed the iliotibial tract was tender on palpation and the patella (knee cap) laterally caused pain at the ITB.  In August 2007 the CI reported 10/10 pain in the left knee.  There was anterolateral rotatory instability with no active pivot shift.  There was no effusion, no edema, no warmth, no evidence of anterior or posterior instability or meniscal tears and the scar was well healed with tenderness to palpation at Gerdy’s tubercle (the site of insertion of the ITB on the tibia laterally).  As a result the CI was unable perform the duties of a soldier.

A permanent L3 profile was issued on 20 August 2007 with limitations on military functional activities and no physical fitness testing or training other than upper body weight training.  The commander’s statement dated 27 August 2007 indicated the CI had left knee pain and her profile kept her from working in her MOS.  She could not bend, kneel, climb on or off vehicles and could not lift anything over 25 pounds, which resulted in decreased performance since her injury.  At the MEB examination, the CI reported on DD Form 2807-1 dated 4 September 2007 left knee pain and swelling since 2005 and left knee surgery 3 October 2005 for an ITB release and to remove a growth.  The MEB physical examiner noted on DD Form 2808 dated 4 September 2007 left leg incisional scars.  An annotation dated 17 September 2007 indicated the ROM measurements were performed by the NARSUM examiner.  

The MEB narrative summary (NARSUM) dated 17 September 2007 noted the CI’s left knee baseline daily pain was 4/10 in intensity.   With normal activity it was 7-8/10, and at least twice a month it was 10/10 during which time she could barely walk and had occasional swelling of the left knee.  Her left knee ROM measurements were flexion 135 degrees with pain at the extreme (Normal 140 degrees) and extension -5 degrees with pain at the extreme (Normal 0 degrees).  The CI stated she was unable to climb on, off, and under vehicles and could not lift heavy parts or bend.  The examiner’s diagnosis was chronic left knee pain with a history of iliotibial band syndrome status post-surgery.  

At the VA Compensation and Pension (C&P) examination dated 10 October 2007, performed 2 months before separation, the CI reported left knee pain along the lateral aspect that was present daily and recurrent swelling in the area once or twice a week.  The knee pain initially began around April 2005 in the absence of any specific injury.  She underwent surgery in October 2005 and had physical therapy thereafter.  Postoperatively her symptoms improved until approximately 6 months earlier when they recurred.  She was unable to run, bend, and lift and she used a firm knee brace.  On examination of the lateral aspect of the left knee there was a 9 cm x 5 mm healed depressed, shiny, non-tender and non-adherent superficial scar.  There was no left knee focal tenderness, heat, redness, or effusion.  The CI’s gait was mildly antalgic and she was unable to do squats.  Her knee was stable without evidence of a meniscal tear.  Flexion was 0-112 degrees with pain at 110 degrees.  There was no additional loss of ROM due to pain, weakness, fatigability, incoordination, or instability.  The examiner’s diagnosis was left knee osteochondroma, status-post iliotibial band release and removal of the bone growth, with recurrent chronic pain and a chronic iliotibial band syndrome.

The 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.

Left Knee ROM
(Degrees)	PT ~23 Mos. Pre-Sep
	MEB ~3 Mos. Pre-Sep
	VA C&P ~2 Mos. Pre-Sep
	
Flexion (140 Normal)	130	135	112	
Extension (0 Normal)	0	-5	0	
Comment	Tenderness on palpation along the scar-minimal	Pain at the extreme	Pain at 110; DeLuca negative; mildly antalgic gait; no laxity or meniscal signs	
§4.71a Rating	0%	0%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 (Degenerative arthritis) for chronic left knee pain.  The VA assigned a 10% rating using code 5299-5014 (Osteomalacia) for a left knee osteochondroma with iliotibial band syndrome status post-surgery (also claimed as left knee chondromalacia).  The Board sought a route for a higher rating and considered using code 5099-5003 at 10% since the ROM measurements proximate to separation were noncompensable, but there was pain on motion at the VA examination 2 months prior to separation.  Additionally, the Board considered analogous code 5262 (Tibia and fibula impairment-malunion with slight knee disability) at 10% since the CI had an osteochondroma removed (although the STR did not have either a primary source operative or pathology report) and both knee pain and functional limitations persisted.  In the absence ankylosis, moderate subluxation (although there was one finding of anterolateral rotatory instability), meniscal involvement, or tibia and fibula impairment with moderate or marked knee disability, the Board was unable to find a route to higher rating.  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 chronic left knee pain 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 chronic left knee pain was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  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 Knee Pain 	5099-5003	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 XXXXXXXXXXXXXXXXXXXXXXXXX, AR20160000442 (PD201400347)

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:

CF: 
(  ) DoD PDBR
(  ) DVA