RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00611
BRANCH OF SERVICE:  Army	SEPARATION DATE:  200601106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-2 (Trainee) medically separated for a right and left knee pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right and left knee conditions, characterized as “chronic bilateral knee pain, right worse than left” was forwarded to the Physical Evaluation Board (PEB) as failing retention standards IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic right knee pain” and “chronic left knee pain” as unfitting, rated 10% and 0%, respectively, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI states his conditions continue to worsen.  His complete submission is at Exhibit A.

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 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 20061011	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5099-5003	10%	PFS Right Knee	5299-5260	10%	20070312	
Chronic Left Knee Pain	5099-5003	0%	PFS Left Knee	5299-5260	0%	20070312	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070411 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right and Left Knee Conditions.  The service treatment record (STR) documented that the CI twisted his right knee during physical fitness training in June 2006 (2 weeks after entry).  Radiographic evaluation on the date of injury documented no visible fractures, dislocation or effusion.  Further imaging one week later demonstrated a “mild contusion” of the distal thigh bone (medial femoral condyle) and proximal lower extremity (medial and posterolateral tibial plateau) with mild soft tissue swelling and no evidence of internal joint injury.  At an orthopedic visit in July 2006 (4 months pre-separation), the CI reported intermittent locking and buckling.  The examiner diagnosed patellar chondromalacia.  At physical therapy visit 4 days later, the examiner noted crepitus and prescribed a hinged knee brace.  At another physical therapy visit in July 2006, the CI first reported bilateral knee pain, right greater than left.  The examiner documented a normal gait and full flexion with no specific exam of the left knee.  The right knee exam had crepitus with range-of-motion (ROM), tenderness at the medial joint line and with patellar mobility.  There was no evidence of swelling, laxity or meniscal injury (anterior/ posterior drawer and McMurray tests).  During an orthopedic visit in August 2006 (3 months pre-separation) the CI reported bilateral knee pain that increased with prolonged standing, marching and running.  The examiner documented the bilateral knee exam as having full ROM, and otherwise stable.  There was evidence of patellar grind, and tenderness medially above and below the right knee joint (at the femoral condyle and tibial plateau).  No specific exam of the left knee was documented.  During a physical therapy visit in August 2006, the examiner documented a normal gait and normal strength of the bilateral lower extremities.  Right knee pain occurred with rising from a squatted position and flexion was limited by pain to 105 degrees.  The right knee had crepitus, and no locking or give way.  Left knee flexion was 135 degrees (normal 140) and extension was normal (0 degrees).  A bone scan reportedly showed mild stress related uptake in both knees and no evidence of focal stress fracture.  

The MEB Narrative Summary (NARSUM) exam was performed on 29 August 2006, 3 months pre-separation.  The CI reported bilateral knee pain (right greater than left), with the left knee pain starting during physical therapy for the right.  The knee pain was exacerbated by prolonged standing and sitting.  The examiner documented a normal gait, sensation, and strength without visible effusion.  Right knee range-of-motion was 0-105 degrees (normal extension 0 and flexion 140).  There was tenderness medially above and below the right knee (both the femoral condyle and tibial plateau).  Left knee ROM was 0-135 degrees.  There was tenderness along the left medial patella with grinding noted.  There was no joint line tenderness, or findings of meniscal injury, instability, or significant laxity of either knee.  

At the VA Compensation and Pension (C&P) exam (performed on 12 March 2007; 4 months post-separation), the CI reported daily pain in both knees (right greater than left), stiffness and weakness, and felt as if the right knee “dislocated” if he turned a certain way (rare occurrence).  He denied falls, missed work days, and use of assistive devices.  The examiner documented a normal gait with full right knee extension; and flexion limited by pain to 120 degrees.  Repetition limited flexion to 110 degrees (due to pain and fatigue).  Crepitus was noted on the right.  The left knee range-of-motion was normal without pain or crepitus and did not change with repetition.  There was no evidence of meniscal injury, instability, or laxity of either knee.  Radiographs in March 2007 of the right knee were normal; while the left knee showed a minor abnormality of the distal femur which might have represented “normal variant vs trauma.”  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the right and left knee conditions as unfitting, rated 10% and 0%, respectively, analogously coded as 5099-5003 (degenerative arthritis).  The VA rated 10% and 0% for the right and left knees respectively, analogously coded 5299-5260 (leg, limitation of flexion).  

Right Knee Condition.  The Board considered the evidence for a higher rating.  There was no evidence of flexion limited to 30 degrees, or extension limited to 15 degrees to support a higher rating.  There was no documentation of frequent episodes of locking or effusion into the joint to support a higher rating under the meniscal codes.  There was no documentation of recurrent subluxation or lateral instability, or ankylosis.  There was evidence of painful motion, crepitus, with limitation of motion that persisted after separation and supported a 10% rating analogously coded 5099-5003 or 5299-5260.  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 right knee condition.  

Left Knee Condition.  There was no STR evidence of flexion limited to 45 degrees, or extension limited to 10 degrees to support a higher rating.  There was no documentation of frequent episodes of locking or effusion into the joint to support a rating under the meniscal codes.  There was no documentation of recurrent subluxation or lateral instability, or ankylosis.  There was pre-separation evidence of tenderness, crepitus, with slight limitation of motion that resolved at the time of the VA examination, establishing a lack of chronicity, and therefore no grounds for a permanent disability rating.  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.  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 right and left knee conditions 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 20130123, 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 XXXXXXXXXXXXXXXXXXXXXXX, AR20160003078 (PD201400611)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA