RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00556
BRANCH OF SERVICE:  Army	BOARD DATE:  20150415
SEPARATION DATE:  20061124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantry) medically separated for right knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty, but he was authorized to perform alternate physical fitness testing.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Left knee pain, patellofemoral pain syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic right knee pain” as unfitting, rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The VA has rated me significantly higher than 0% and also is still under review.  I have very little range of motion in both knees, walk with cane and can’t even get out of bed 50% of the time.”

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 20060817	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5009-5003	0%	Right Knee Condition	5299-5260	NSC	20070123	
Left Knee Pain, Patellofemoral Pain Syndrome	Identified by MEB
Not-Unfitting	Residuals Meniscal Tear, Left Knee	5299-5260	0%	20070123	
Other x 0 (Not in Scope)	Other x 7	
Combined:  0%	Combined:  40%	
*Derived from VA Rating Decision (VARD) dated 20070327

ANALYSIS SUMMARY:  The narrative summary (NARSUM) references the right and left knees, which appears to the Board to have been due to the MEB examiner referring to the right knee in error rather than the left knee, which is the knee that is referenced by the history of knee injury and treatment in the cited facts of the case and the MEB examination provides a diagnoses of the left knee.  However, the PEB adjudication listed the right knee condition and no administrative corrections to the PEB are available in record.  The CI contended both the knees, and as noted in the scope section above, the Board consensus was that this adjudication and contention places both knees in the scope of the Board’s review.  There is scant information in the available record and therefore the facts are presented together for the bilateral knees with individual recommendation for fitness, if applicable, and rating recommendations.

Bilateral Knee Conditions.

Left Knee.  The NARSUM notes a chief complaint of right knee pain.  However, the history of present illness section references a hyperextension injury to the knee, followed by physical therapy (PT), magnetic resonance imaging (MRI), and arthroscopic surgery on February 2003.  The injury, MRI, and surgery involved the left knee as supported by other documents in record, including the initial VA Compensation and Pension (C&P) examination summarized below.  Following the surgery the CI deployed and improved because he was not running.  After return from deployment the knee pain returned.  The CI was treated with another 6 months of PT and evaluated by podiatry and given orthotics, which did not improve his pain.  The NARSUM listed imaging studies as excerpted below:

“Knee X-rays on 4 April 2006 noted “s/p lt knee scope without meniscal pathology in 2003 with persistent knee pain. r/o progressive DJD” and X-rays of the left knee were normal.  On 2 October 2002 there was a bilateral scanogram with reported normal knees.  Left knee MRI on 2 September 2002 noted degenerative changes of the medial meniscus and a small Baker’s cyst.  Left knee X-rays 3 September 2002 were normal.”

Notes from the health record were listed for three dates.  Two notes in 2002 noted left knee pain after running.  A note regarding the 11 March 2003 arthroscopy indicated “Normal Knee Arthroscopy:  No debridement was done.  The MRI finding could not be confirmed under direct observation.”  Consultations were listed, but the original notes were not available in the record.  An orthopedic consult on 4 April 2006 was summarized as “Left Patello Femoral Pain Syndrome without meniscal or chondral pathology.  Initiate P3 profile and MEB.”

At the MEB NARSUM examination on 11 July 2006, 5 months prior to separation, the CI reported knee pain and a past history of right knee pain.  The MEB NARSUM referenced the range-of-motion (ROM) measures taken during the MEB DD Form 2808, Report of Medical Examination, dated 27 June 2006, 7 months prior to separation.  There CI was noted to have a normal gait and stance.  Right knee ROM was extension-flexion of 0-150 degrees (normal 0-140).  Left knee ROM was minus 1 (hyperextension) to 123 degrees, repeated 3 times, limited by pain.  Both knees were noted to be stable, with normal lower extremity strength.  The MEB examiner noted only the left knee in discussion of the CI’s present condition.  The permanent profile listed left knee pain.  The commander’s statement implicated bilateral knee pain as impairing the CI’s duty performance.

At the VA C&P examination 23 January 2007, 2 months after separation, the CI reported pain beginning in March 2002 when he hyperextended his left knee while running and that his right knee quickly began to hurt due to compensation for the left.  He reported constant moderate pain without swelling or instability and difficulty squatting, standing, or walking more than a quarter of a mile.  The examiner noted the CI had surgery for the left knee in March 2003 for repair of a meniscal tear and had no history of surgery on the right knee.  He denied use of a cane or crutches.  ROM was reported for the bilateral knees as 0-136 degrees, pain free, and not additionally limited by repetitive use.  There was no crepitus or evidence of current meniscal injury or instability.  At a VA C&P examination on 13 August 2007, 9 months after separation, the CI reported his right knee symptoms were secondary to the left knee injury.  The VA exam catalogued visits from the service medical records as excerpted below”

“A Medical Evaluation Board document 10/18/06 showing anterior cruciate ligament disruption, patellofemoral syndrome of the knees 12/02/02 of bursitis of the left knee and X-ray 09/16/06 shows medial meniscal tear.  Medical evaluation board of 06/27/06 showing the right knee was stable.  A visit of 06/21/05 showing that there is right knee crepitus.”

The CI was noted to be using a cane and a brace for the left knee.  The exam noted bilateral tenderness and knee ROM of 0-50 degrees with painful motion.  There were no other abnormal findings of the right knee  The left knee ROM was additionally limited by repetition to 0-30 degrees.  The examiner noted mild crepitus and patellar pain with compression on the left with a mild positive anterior drawer sign, but a negative Lachman’s testing (both tests for instability).

The Board directed attention to its fitness and rating recommendation for the knee condition based on the above evidence.  The PEB rated the knee condition 0%, coded 5099-5003 and noted “rated for pain - minimal and frequent.”  The PEB DD Form 199 listed chronic right knee pain, however, further described the condition as a result of the hyperextension sprain in 2002, which is supported by evidence in the record to have been injury to the left knee.  Members deliberated that the evidence strongly supports that the left knee was unfitting for continued service.  The left knee was permanently profiled and implicated in the commander’s statement.  The MEB NARSUM clearly outlined that the left knee condition impaired the CI’s duty performance.  The Board therefore, agreed that the evidence supports that the left knee was unfitting at the time of separation and eligible for rating.  The Board next deliberated the rating of the left knee.  The VA initially rated the left knee 0%, coded 5299-5260 (analogous to limited leg flexion).  The VARD on 22 October 2007 increased the rating of the left knee to 10%.  Members agreed that the evidence at the MEB examination and the initial C&P examination supports a 10% rating with a ROM code IAW §4.71a based on painful motion IAW §4.59 (painful motion).

Members additionally discussed the exam findings at the C&P following the original VARD and the CI’s Notice of Disagreement.  The bilateral knee ROM at the 13 August 2007 C&P exam was markedly diminished compared with the MEB and initial C&P exams.  The Board deliberated how to reconcile the discrepancies.  The Board considered that the later C&P examiner may have reported ROM as the point at which pain began and not the point beyond which the CI could not move the joint.  Alternatively, the exam may indicate that there was significant after separation worsening of both knees, however, there was no explanation of the findings that linked them to the CI’s condition at separation.  In this case the Board did not think that the C&P further from separation reflected disability at the time of separation better than the MEB and the initial C&P exam (the most proximate examination to the date of separation [DOS]) and there were no later ROM evaluations to clarify the issue.  Therefore, the Board consensus was that the ROM evidence at separation supports a 10% rating.

The Board also reviewed to see if any higher evaluation was achieved with any applicable §4.71a code.  There was no evidence instability, semilunar cartilage related symptoms or removal, or impairment of the femur, tibia, or fibula resulting in knee disability, and no evidence of any other ratable impairment of the knee.  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 left knee condition, coded 5299-5260.

Right Knee.  The Board next considered the rating of the right knee condition.  Members discussed the dilemma posed by the PEB adjudication.  As noted above a single unfitting knee condition was rated 0%, supported in the record to be in actuality the left knee.  The Board noted that the evidence in record that both knees were unfitting at separation was limited to the commander’s reference to the CI’s problems with his “knees.”  The right knee was not permanently profiled and there was no evidence that the right knee condition significantly impaired satisfactory duty performance.  Though the right knee was listed on the DD Form 199, apparently in error, it was nevertheless rated.  Therefore, the Board proceeded with a rating recommendation for the right knee.

There was no imaging of the right knee during the service except as part of one bilateral scanogram, which reported normal knees.  Two sets of X-rays and MRI were of the left knee only.  The right knee exam was normal at the MEB NARSUM examination (referencing the DD Form 2808 exam) and the initial C&P examination noted slight, painless, limitation of flexion of 136 degrees.  Bilateral knee ROM at the second C&P examination 9 months after separation was markedly diminished compared with the MEB NARSUM (DD Form 2808) and initial C&P exams.  However, as previously elaborated in the discussion of the rating of the left knee condition, the Board opined that the MEB NARSUM (DD Form 2808) exam and the initial C&P exam (the most proximate examination to the DOS) were the most probative exams for its rating recommendation for the CI’s disability due to the knee condition at the time of separation.  Therefore, the Board consensus was that the evidence in record at the time of separation supported only a 0% rating of the right knee, coded as either as 5003 or 5260 for limited flexion not meeting the threshold for a 10% rating based on limited ROM alone and there was no evidence of painful ROM or pain with use of the right knee for consideration of §4.59 or §4.40 (functional loss).

The Board also reviewed to see if any higher evaluation was achieved with any applicable §4.71a code, but there was no evidence of instability, semilunar cartilage related symptoms or removal, or impairment of the femur, tibia, or fibula resulting in knee disability, and no evidence of any other ratable impairment of the knee.  Therefore, the Board consensus was that the evidence at separation supports a 0% rating for the right knee condition.  After due deliberation in consideration of the preponderance of evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition and no additional disability rating is 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the right knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the contended left knee condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 5299-5260 IAW VASRD §4.71a.  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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Left Knee Pain, Patellofemoral Pain Syndrome	5299-5260	10%	
Chronic Right Knee Pain	5099-5003	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140107, 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 XXXXXXXXXXXXXXXXXXXX, AR20150013272 (PD201400556)

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