RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00667
BRANCH OF SERVICE:  Army	BOARD DATE:  20150505
SEPARATION DATE:  20060613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Military Police) medically separated for chronic right knee pain.  The condition 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 profile and referred for a Medical Evaluation Board (MEB).  The right knee conditions, characterized as “… saphenous nerve neuropraxia”, “S/P (status post) … anterior cruciate ligament (ACL) construction” and “… patellofemoral pain syndrome” were 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 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  The applicant makes no specific contention in his application.  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 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 after separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board gives consideration to DVA 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 20060601	VA* – ~7 Mos. Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain…	5099-5003	10%	Right Knee, Status Post Anterior Cruciate Ligament
Reconstruction…	5260-5014	10%	20061229	
Right Knee Saphenous Nerve Neuropraxia	Not Unfitting	Residual Right Lower Extremity Nerve Damage…	8599-8527	10%	20061229	
Other x 0 (Not In Scope)	Other x 0	
RATING:  10%	COMBINED:  20%	
*Derived from VA Rating Decision (VARD) dated 20070226 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Knee Condition.  The service treatment record (STR) documents that on 5 August 2005 the CI’s right knee collapsed during a ruck march in the Warrior Transition Course.  The emergency medicine encounter that same day documented the CI had a right knee twisting injury 2 weeks prior to the training injury.  The CI ultimately was evaluated by orthopedic surgery because of continued knee pain and instability.  A magnetic resonance imaging (MRI) study demonstrated a right ACL rupture.  On 9 December 2005 he underwent an arthroscopic right knee ACL reconstruction with a hamstring tendon segment (autograft).  The orthopedic surgery narrative summary (NARSUM) written 2 months prior to separation recounted the history of the injury and surgery.  About a month post-operatively, his recovery was complicated by “a fall and a pull.”  He developed significant knee pain and continued to have incapacitating pain despite intensive physical therapy.  “His knee appeared stable throughout his follow-up X-rays [February 2006] without any evidence of fracture and tunnel appears to be in good position.” The CI complained of “pain both anteriorly and posteriorly … the knee pops and clicks and does lock…pain…constant and marked.”  The physical exam showed the CI walked with “a normal heel-toe reciprocal gait.”  The right knee exam demonstrated multiple well-healed incisions and tenderness with no infection or effusion (fluid collection).  There was no evidence of instability by lateral/medial (varus/valgus) stress testing.  Lachman's, drawer, and pivot shift tests (to assess the integrity of cruciate ligaments) were negative.  The goniometer-measured right knee range-of-motion (ROM) is listed in the chart.  There was normal (5/5) strength, right quadriceps atrophy, and decreased sensation medially from mid-calf to foot.  The diagnoses listed status post right knee ACL reconstruction, right knee saphenous nerve neuropraxia (transient loss of nerve conduction in the absence of structural changes), and right knee patellofemoral pain syndrome (a symptom complex of anterior knee pain involving the patella).  The Compensation and Pension (C&P) exam by neurology 7 months after separation recounted the history and interventions to date.  The examiner documented “… since reconstruction he has had right knee pain … medially … sharp … achy … [and] … also has stiffness, weakness and swelling.”  The CI complained of instability, giving way, heat, and redness but denied pain flare ups or recurrent subluxation/dislocation.  The CI reported he “uses a knee sleeve at most times … a knee brace … when he is working … [as] … a police officer.”  Physical exam documented a normal gait without an ambulatory aid and no functional limitations of standing or walking.  The right thigh had evidence of atrophy compared to the left.  Muscle strength was decreased in the right quadriceps compared to the left (not quantified).  There was “evidence of loss of pinprick and light touch in the right leg medially, in the saphenous and tibial nerve distribution.”  Right knee exam revealed medial tenderness and healed surgical scars.  There was no spasm, weakness, fatigue, edema, effusion, heat, redness, ankyloses, inflammatory arthritis, instability, or guarding.  There was no instability or ligamentous laxity “ACL, PCL, MCL, LCL and McMurray testing was negative.”  The goniometer- measured right knee ROM, with pain throughout range, was seen as listed in the chart.  On repetitive testing, ROM values were unchanged from baseline testing and without fatigue, weakness, or incoordination.

The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Knee ROM
(Degrees)	Ortho ~4 Mo. Pre-Sep	NARSUM ~2 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	
Flexion (140 Normal)	“ROM 10-125”	130	130	
Extension (0 Normal)	 “ROM 10-125”	5	-5	
Comment	4 Mo. Post-Op	Goniometer Used	Goniometer Used/Pain on ROM	
§4.71a Rating	10%	0%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB, a month prior to separation, rated the right knee condition at 10%, coded 5099-5003 by analogy, to degenerative arthritis.  The PEB cited s/p ACL repair, pain and crepitus with full motion, good stability, and no degenerative joint disease.  The VARD rated the right knee condition at 10%, coded 5260-5014 (leg, limitation of flexion-osteomalacia).  The VARD cited painful or limited motion of a major joint.  The MEB and C&P exams did not demonstrate limitation of motion to support a minimum rating under VA codes 5260 or 5261 (limitation of flexion or extension).  There was no instability or dislocated meniscus to support minimum ratings under the respective codes 5257 or 5258.  Board members agreed that there was sufficient evidence of painful motion (VASRD §4.59) prior to separation, as well objective exam findings, to support a 10% rating under 5099-5003.  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.

Contended PEB Condition (Right Lower Extremity Nerve Condition (RLE).  The Board’s main charge is to assess the fairness of the PEB’s determination that the right lower extremity nerve condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The STR documents that following his right knee ACL reconstruction, the CI experienced altered sensation in his right leg.  The NARSUM reported the CI experienced post-operative medial right leg and foot numbness, which failed to resolve with time.  The lower extremity exam documented normal (5/5) strength, right quadriceps atrophy, and decreased sensation medially from mid-calf to foot.  The diagnosis listed right knee saphenous nerve neuropraxia.  The C&P exam reported that “after the surgery…he had numbness located in the medial aspect of his right leg down to his ankle…feeling like pins and needles.”  The physical exam documented that the right thigh had evidence of atrophy compared to the left.  Muscle strength was decreased (not quantified) in the right quadriceps compared to the left.  There was “evidence of loss of pinprick and light touch in the right leg medially, in the saphenous and tibial nerve distribution.”

The Board directed attention to its rating recommendation based on the above evidence.  Both the NARSUM and C&P exams documented increased right quadriceps/thigh atrophy compared to the left.  The NARSUM exam documented normal (5/5) strength while the C&P exam did not quantify the decreased right quadriceps strength.  Recovery from ACL injury/repair commonly results in persistent muscle atrophy and weakness.  These findings are the typical expected sequela (after effect) of this type of surgery.  The atrophy results from many causes to include anatomical changes at the graft donor site and disuse atrophy.  The neurologic impairment involved sensory function (altered sensation) and did not appear to involve motor function.  The circumscribed sensory deficit did not interfere with knee function or performance of duties.  The RLE nerve condition was not profiled or implicated in the commander’s statement.  The MEB and PEB found the nerve condition met retention standards, was not unfitting, and therefore not rated.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition; and, therefore, no additional 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.  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 right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended RLE nerve condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20131217, 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, AR20150018812 (PD201400667)

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