RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00469
BRANCH OF SERVICE: Army	BOARD DATE:  20140806
SEPARATION DATE:  20070905

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (13D/Fire Direction Specialist) medically separated for a right knee condition.  The right knee could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3/S3 profile and referred for a Medical Evaluation Board (MEB).  The knee condition, characterized as “osteoarthritis right knee”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions; posttraumatic stress disorder (PTSD) as not medically acceptable and 2 conditions as not falling below retention standards.  The Informal PEB adjudicated “chronic right knee pain secondary to chondromalacia” as unfitting, rated 0%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The PEB further adjudicated the PTSD as not unfitting along with the other two conditions forwarded by the MEB.  The CI appealed to the Formal PEB, which affirmed the PEBs findings and ratings.  The CI was then medically separated.

CI CONTENTION: The CI elaborated no specific contention in his 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 those conditions identified but not determined to be unfitting by the PEB, when specifically requested by the applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service FPEB – Dated 20070718	VA - (Same Mo. As Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic R Knee Pain secondary to Chrondromalacia	5099-5003	0%	R Knee Contusion w/Resulting Osteochondral Defect	5261	10%	20070919	
PTSD	Not Unfitting	PTSD	9411	10%	20070719	
Other x 2 (Not in Scope)	Other x 5	20070919	
Combined:  0%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20080527 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Right Knee Pain.  The narrative summary notes the CI injured his right knee while deployed in 2003 when the knee hit a table and he experienced immediate pain and swelling.  He was treated conservatively with little change in his symptoms but was deployed a second time.  When he returned he was evaluated by an orthopedic specialist.  Right knee X-rays on 15 November 2006 showed degenerative changes of the knee with a loose body (bone/cartilage) in the joint.  The CI had surgery on 30 November 2006.  The loose body was removed, a cartilage defect of the femoral condyle and degenerative changes of the patellofemoral joint were noted.  At the orthopedic follow up on 5 March 2007 the CI continued with knee pain.  On examination a slightly antalgic gait and stance were noted and right knee range-of-motion (ROM) was full with painful motion.  There was patellar crepitus and tenderness, without joint laxity, instability or joint line tenderness noted, with intact lower extremity strength, sensation and pulses.  The CI was given an L3 profile and referred for an MEB.

At the MEB examination on 25 April 2007, approximately 4 months prior to separation, the CI reported pain with stairs or sitting for long periods, occasional “giving way”, but no locking of the knee.  The MEB physical exam cited the 5 March 2007 orthopedic examination noted above.

At the VA Compensation and Pension (C&P) examination performed the same month as separation, the CI reported mild daily pain in his right knee after surgery, which limited running.  The CI reported being employed and had not missed any work in the past year.  The examination noted normal gait, without use of a cane and normal strength, sensation and reflexes of the lower extremities.  Right knee ROM was extension-flexion of 10 degrees – 80 degrees, limited by pain, without joint laxity or instability.

The Board directs attention to its rating recommendation based on the above evidence.  The Formal PEB rated chronic right knee pain 0%, coded as 5099-5003 (degenerative arthritis).  The VA rated the right knee at 10%, coded 5261 (limited knee extension).  The evidence in record supports that the CI had residual right knee pain with degenerative changes with patellar crepitus noted at orthopedic visits, but full ROM, with no instability.  Painful joint motion was noted at both the MEB and C&P examinations and the CI reported pain with weight bearing activities.  The Board first considered coding as 5099-5003 as the PEB did and agreed that a 10% rating was met for evidence of degenerative arthritis with painful and limited motion.  The Board reviewed to see if a higher rating was achieved with any other code IAW §4.71a.  The Board noted that coding as 5099-5261 for patellofemoral syndrome (analogous to limited extension) also resulted in a 10% rating; a compensable rating was not achieved based upon ROM criteria alone with 5260 (flexion); and, a 10% rating was achieved coding as 5261 for extension to 10 degrees, but the 20% rating was not met for extension limited to 15 degrees.  The Board discussed coding analogously to 5262 (knee disability due to impairment of the tibia or fibula) with subjective 10%, 20% and 30% ratings of slight, moderate or severe knee disability and agreed that the reported mild daily knee pain with a normal gait reported by the CI at the C&P examination, the most proximate examination to separation, was most consistent with the 10% rating.  The Board agreed, that although a 10% rating could be arrived at with more than one coding choice, a higher evaluation was not achieved and the Board chose to code as 5099-5003 for degenerative arthritis.  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 right knee pain condition.

Contended Mental Health Condition.  There were no primary MH evaluations or treatment notes in the service treatment record (STR).  Notes in the STR indicated history obtained during the MEB process for the CI’s knee condition noted anxiety symptoms and the CI was referred to psychiatry to complete the MEB.  The DD Form 2808, Report of Medical Examination, listed “Depression/Adjustment Disorder/Insomnia.”  The psychiatrist evaluation on 2 April 2007, approximately 5 months prior to separation, noted that the CI had never sought MH treatment but reported insomnia, sadness and anxiety related to deployment experiences.  The CI reported being anxious and uncomfortable in crowds and hypervigilant with intrusive thoughts of events during deployment.  The mental status examination noted a sad and anxious mood, with an otherwise normal examination.  The Axis 1 diagnosis was chronic PTSD with insomnia as the main complaint.  The MEB psychiatric addendum noted the same history and mental status exam (MSE) as the initial psychiatric evaluation with an Axis 1 diagnosis of chronic PTSD and a Global Assessment of Functioning (GAF) of 85 (minimal to no impairment range).  The psychiatric profile was S1 at the MEB medical examination on 12 February 2007 and changed to S3 following MEB psychiatric addendum in April 2007.  The initial commander’s statement on 27 March 2007 noted only impairment due to a non-MH condition.  A statement from the CI’s Platoon Sergeant on 24 May 2007 and an update to the commander’s statement on 15 May 2007 addressed being notified of the PTSD diagnosis and confirmed the CI’s exposure to combat stressors.  However, both statements reaffirmed the CI’s excellent duty performance with demonstrated ability to work well with supervisors, co-workers and subordinates with “superb duty performance” noted by the Platoon Sergeant and “no detrimental effects” to duty performance noted by the commander.

At the VA C&P Mental Disorders examination on 19 September 2007, 2 weeks after separation, the CI reported sleep disturbance with nightmares, combat-related intrusive memories and flashbacks, hypervigilance, avoidance, slight suspiciousness and paranoia, decreased appetite, periods of sadness, anxiety, irritability occasional panic like symptoms and seeing things out of the corners of his eyes, but denied frank hallucinations or suicidal ideation (SI).  The CI reported that medication for mood was helpful, but for nightmares was not.  The CI reported that since military separation he was employed making military parts and that his job upset him because it reminded him of the military.  He had not missed any work and after work he spent time with his family and he had maintained some friends from the military.  The CI reported no history of psychiatric hospitalizations, legal problems or significant substance abuse issues.  The MSE noted “emotional lability under the surface” but a blunted affect and mild decreased short term memory, with an otherwise normal examination.  The Axis 1 diagnoses were PTSD and depression, not otherwise specified with a GAF of 56 (moderate impairment range).  The examiner characterized the CI’s MH signs and symptoms as “transient or mild” that would cause occupational impairment “only during periods of significant stress.”  The VA rendered a diagnosis of PTSD, rated 10%, approximately 9 months after separation.

The Board directs attention to its recommendations based on the above evidence, incorporating the MH Review Program stipulations as elaborated above.  The Board reviewed the records for evidence of inappropriate changes or elimination of diagnosis of the MH condition during processing through the disability evaluation system.  On the DD Form 2808 for the MEB the examiner listed “Depression/Adjustment Disorder/Insomnia.”  The MEB psych addendum listed PTSD and the MEB forwarded PTSD to the PEB for adjudication.  Since the service acknowledged and adjudicated the PTSD condition, this case does not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The PTSD condition was determined to be not unfitting by the PEB.  The SRP’s charge with respect MH conditions referred for review that were determined to be not unfitting by the PEB is an assessment of the appropriateness of the PEB’s fitness adjudication.  The SRP’s threshold for countering PEB not-unfit determinations requires a preponderance of evidence.  The Board considered the CI had not sought MH treatment until referred for reported MH symptoms during the DES process.  The MH condition was not profiled prior to the CI referral into the DES process for non-MH conditions or implicated in the initial commander’s statement.  The updated commander’s statement stated directly that the newly diagnosed MH condition had not impaired duty performance, an assessment supported by the Platoon sergeant.  There was no indication from the record that the MH condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the SRP concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the MH condition, and, therefore, no disability ratings can be recommended.

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 chronic right 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 MH condition, the Board unanimously recommends no change from the PEB determination as not unfitting.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Right Knee Pain	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131125, 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, AR20140019625 (PD201400469)

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