RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00662
BRANCH OF SERVICE:  Army 		SEPARATION DATE:  20040813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Mental Health Technician, medically separated by the Informal Physical Evaluation Board for “pain right knee,” with a disability rating of 10%.

CI CONTENTION:  “Further complications and worsening conditions to my injury.  Initial injury complicating left knee.  Initial injury anterior cruciate ligament tear, medial meniscus tear.  I also have nerve damage to right knee.”  His 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 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 – 20040502	VARD - 20040813	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Right Knee	5099-5003	10%	ACL, Right Knee Reconstruction	5299-5260	10%	STR	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Right Knee Pain.  According to the service treatment records (STR) and the narrative summary (NARSUM), the CI had a history of five right knee surgeries.  The CI had reconstruction of the anterior cruciate ligament (ACL) in 1998, with two re-injuries and two additional surgeries for reconstruction revision, arthroscopic surgery for meniscal debridement in October 2000, and arthroscopic surgery for repair of the joint cartilage in April 2003.  There were scant notes from the STR in record, but there was no mention of continued knee instability in eight physical therapy visits after the last surgery between 21 April 2003 and 9 May 2003.  An orthopedic evaluation on 2 May 2003, 14 months before separation, noted “mild pain, O/W well.”  The exam noted a mild effusion with right knee range-of-motion (ROM) of extension 0 degrees (normal 0) and flexion 85 degrees (normal 140).  Despite all 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 a Medical Evaluation Board (MEB).

At the MEB exam on 9 November 2003, performed 9 months before separation, the CI reported right knee pain.  The MEB physical exam noted tenderness to palpation of the joint lines.  Knee ROM was extension 0 degrees and flexion 90 degrees.  There was no evidence of posterior or lateral instability.  There was a “1+ Lachman’s with a firm end point”.  There was pain with grinding and rotating of the knee in flexion (positive McMurray’s test).  A primary care visit on 9 March 2004 (for goniometric ROM measurement), 4 to 5 months before separation, noted knee pain and knee ROM was extension 0 degrees and flexion of 95 degrees.

The initial VA Rating Decision was based upon STR and there was no evidence that a subsequent VA Compensation and Pension (C&P) exam was performed.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis) and cited the US Army Physical Disability Agency pain policy.  The VA rated the knee 10% based upon service medical records, but coded 5299-5260 (analogous to limited leg flexion).  The Board agreed the evidence in record supports a 10% rating for the knee condition at separation coded as 5003, 5299-5260 IAW VASRD §4.59 (painful motion), or 5259 (symptoms after removal of semilunar cartilage).  The Board noted that any one of these three codes could be utilized, but only one rating could be provided for painful-limited knee motion IAW VASRD 4.14 (avoidance of pyramiding).

The Board first 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 the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no evidence of malunion or non-union of the tibia, fibula, or femur (5262 or 5255) frequent episodes of “locking”, pain, and effusion into the joint (5258); or, knee ankylosis (5256) to support rating under the respective codes.  The Board next considered if there was evidence to support providing either a higher rating coded alternatively as 5257 (other knee impairment) due to instability or a rating of the knee for instability in addition to the 10% rating for painful motion as deliberated above.  The Board considered that although the CI had a history of three surgeries due to knee instability, there was no evidence of significant residual instability at the time of separation.  The MEB examiner noted a “1+ Lachman’s with a firm end point”, which describes a small amount (1-5mm) of anterior movement with stability testing, but the firm end point indicates an intact ACL.  There was also no mention of instability symptoms at follow-up physical therapy, primary care and orthopedic visits after the final surgery, which was performed approximately 16 months before separation.  Therefore, Member consensus was that the evidence in record did not support higher or additional rating of the knee under 5257.  Thus, the Board determined that the evidence supports a 10% rating for the knee condition and no higher.  The Board noted that the PEB’s reliance on the USAPDA pain policy for rating was not detrimental to arriving at the highest rating and that coding with 5003 criteria and rating a single major joint 10% is VASRD compliant.  Therefore, no change is recommended to the PEB coding choice.  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.

BOARD FINDINGS:  In the matter of the 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.

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 20140128, 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, AR20160003589 (PD201400662)

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