RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00547
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard, E4, Infantryman, medically separated for a “left knee pain” condition, rated at 10%.  

CI CONTENTION:  The CI stated that was given a higher rating for his condition by the VA.  The 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 PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the Physical Evaluation Board (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 - 20070409	VARD - 20071015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Retropatellar Pain Syndrome…	5099-5003	10%	Retropatellar Pain Syndrome with Anterior Cruciate Ligament Tear	5099-5010	10%	20070620	
Partial Anterior Cruciate Ligament Rupture	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in July 2006 while playing volleyball, when he felt a “pop” in his knee with immediate pain and swelling.  Magnetic resonance imaging (MRI) demonstrated a partial anterior cruciate ligament (ACL) rupture.  The CI was evaluated by an orthopedic surgeon and surgery was discussed, but not recommended.  The CI requested and obtained a second orthopedic opinion and again surgery was not recommended due to considerations that surgery might worsen his knee condition.  Despite treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and he was referred for an MEB.  

The permanent profile listed left knee pain and noted physical limitations which would apply equally to both diagnoses of the left knee and indicated that the CI could wear a knee brace. The commander’s statement likewise implicated left knee pain and consequent limitations as impairing the CI’s ability to successfully perform his duties.  The MEB NARSUM listed the two knee conditions as above and noted that the CI fell below retention standards, without specifying if for one or both of the conditions.

At the MEB NARSUM examination dated 2 March 2007, 2 months prior to separation, the CI reported constant knee pain with flares, which were exacerbated by prolonged sitting, stairs, and running.  He felt unstable coming down stairs, but had no locking symptoms.  Physical exam showed an antalgic gait with full range-of-motion (ROM) and no effusion, but there was tenderness to palpation (TTP) and a positive patellar grind test.  Tests for ligamentous instability and meniscus (semilunar cartilage) pathology were negative.  The MEB NARSUM examiner, an orthopedic surgeon (provided the second opinion), diagnosed RPPS and partial ACL rupture and thought that RPPS was the CI’s main problem and that the ACL injury was not causing significant instability or pain.  At an outpatient VA orthopedic evaluation on 23 May 2007, 1 month after separation, the CI reported constant left knee pain.  The knee exam was normal, but did not address stability.  Repeat MRI on 4 June 2007 noted the ACL partial rupture and a meniscal cyst.  At the orthopedic follow-up visit on 19 June 2007, the exam noted normal patellar tracking and full knee ROM, without significant laxity, and no surgery was recommended.  

At the VA Compensation and Pension (C&P) examination on 20 June 2007, performed 2 months after separation, the CI reported left knee stiffness and pain, which became more painful after walking more than a mile, without “locking.”  On examination the left knee ROM (following repetitive movement) was flexion 120 degrees (normal 140) and extension 0 degrees (normal 0).  Further examination showed a “mildly left antalgic gait” and no effusion.   Tests for meniscus pathology were negative and tests for anterior and posterior instability were negative, however there was “slight laxity” to side stress at 30 degrees of flexion.  

The initial VA orthopedic surgeon referred the CI to another VA orthopedic surgeon for consideration of surgery for ACL insufficiency in September 2007.  The orthopedic evaluation on 25 September 2007, 5 months after separation, noted a normal gait.  There was TTP of the patella and a positive grind test.  There was atrophy of the left quadriceps muscle.  Testing for meniscal injury was negative, but testing for anterior laxity/instability was positive (anterior drawer 2+/3, pivot shift 1/3).  The examiner indicated the MRI performed 21 September 2007 showed the ACL tear and a “symptomatic meniscal cyst”, but PT was again recommended before consideration of surgery.  At the follow-up orthopedic visit on 25 October 2007, the CI reported continued pain and the exam noted similar exam findings with anterior laxity noted (anterior drawer 2+/3), but with a firm end point.  The surgeon indicated that X-rays showed a lateral patellar tilt and MRI abnormalities as noted with an impingement syndrome of the knee.  The CI underwent surgery on 30 November 2007 for lateral patellar release and debridement of the joint and ACL and patellar ligaments.  At the time of surgery all of the noted abnormalities were present, and the torn ACL with “loss of tension” was noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition of RPPS 10%, coded 5003, (analogous to arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40) and adjudicated the left knee condition of partial ACL rupture as not unfitting as noted above.  The VA rated the left knee condition 10% coded 5099-5010, (analogous to arthritis, due to trauma), citing painful or limited motion of a major joint.  

The Board first addressed the PEB’s adjudication of the ACL tear as a separate condition of the left knee that was not separately unfitting.  The Board noted that the neither the permanent profile nor the commander’s statement provided support for the PEB’s adjudication of the ACL tear as not unfitting.  The physical limitations noted in both documents would equally apply to both conditions.  The Board also noted that the Ci’s knee pain began suddenly during a sports event, which was consistent with the ACL partial rupture event.  Given this, the Board concluded that it would be impossible to know if in the absence of the RPPS, the ACL rupture would not impair the CI’s duty performance.  The Board also considered that the disability effects of these two conditions of the knee were not reasonably separable for fitness considerations.  After deliberations, Members agreed that there was an unfitting left knee condition and contributions to the disability from the RPPS and partial ACL rupture were appropriately considered in its rating recommendations for the knee condition. 

The Board agreed that the evidence in record of painful motion with functional loss supports a 10% rating for the knee condition coded as 5003 or 5260, 5261 (analogous to either limited leg flexion or extension) based on §4.59, §4.40 and §4.45.  The Board reviewed to see if a higher evaluation was achieved with any applicable code.  There was no limitation of motion which attained a minimum rating under 5260 or 5261.  The MRI shortly after separation noted a meniscal cyst that was symptomatic, but there was no evidence of frequent locking or joint effusions for higher rating coded for a symptomatic semilunar cartilage (5258).  There was evidence of a partial ACL tear prior to separation with positive testing for ACL laxity noted after separation and ACL tear with laxity noted at the surgery 7 months after separation.  Members were satisfied that the evidence cited above provided adequate support for rating under code 5257 (other knee impairment) for knee instability; which confers 10% for “slight” instability, 20% for “moderate,” and 30% for “severe.”  The Board noted that multiple orthopedic opinions, both prior to separation and in the VA evidence in record within 12 months of separation, were in agreement that the instability due to ACL ligament injury was best treated non-operatively.  Therefore, the Board determined that the evidence supports that the contribution to knee disability due to instability was best characterized as slight instability (5257) and rated 10%, but no higher.  The Board next considered whether separate ratings of the knee were warranted in this case or if the knee could only be provided one rating coded either as 5003 (or 5299-5260) or alternatively (but not additionally) as 5257.  Member consensus was that the total evidence in record supports that separate ratings for instability and painful/limited motion of the knee are warranted in this case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating as follows: 10% for knee pain condition, coded 5099-5003 and 10% for knee instability condition coded 5257.  

BOARD FINDINGS:  In the matter of the knee condition, the Board unanimously recommends a disability rating as follows: 10% for knee pain condition, coded 5099-5003 and 10% for knee instability condition coded 5257 for a combined 20% rating IAW VASRD §4.71a at permanent separation  The Board, therefore,  recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior to medical separation

CONDITION	VASRD CODE	RATING	
Left Knee RPPS Condition 	5003	10%	
Left Knee Partial ACL Rupture Condition	5257	10%	
COMBINED 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141117, 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, AR20160005578 (PD201400547)

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 20% 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