RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00844
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080816

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cargo Specialist, medically separated for “right knee pain,” with a disability rating of 10%.

CI CONTENTION:  The applicant made no specific contention.  The CI’s 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 Physical Evaluation Board (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 - 20080507	VARD - 20090202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099- 5003	10%	Instability, Right Knee	5257	10%	20080930	
			Residuals of Right Knee Injury	5261-5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported a history of a knee cap fracture in October 2001 and right knee surgery in April 2002, 6 years before separation, reportedly for meniscal repair and lateral release.  She deployed in 2005 on a L2 profile for right knee pain and finished the deployment, but her knee pain worsened in June 2007 while running.  At treatment visits in the STR the CI reported right knee pain with locking and giving way.  Serial examinations noted tenderness about the patella with functional ROM and no laxity or instability.  Magnetic resonance imaging of the right knee in November 2007 showed swelling within the soft tissues of the knee, especially the medial and lateral collateral ligaments, with a possible partial tear of the medial retinaculum of the patella (connective tissues that secure the patella).  An orthopedic evaluation on 20 November 2007 diagnosed chondromalacia patella and repeat MRI February 2008 was read as normal.  At an orthopedic second opinion evaluation on 21 February 2008, the examinationshowed mild medial and lateral joint line tenderness.  There was no effusion, or evidence of laxity or instability of the knee and maneuvers to elicit meniscal pathology elicited pain both medially and laterally.  The diagnosis was patellofemoral syndrome with some chondromalacia noted on the MRI and no surgery was recommended.   Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “right knee pain” for PEB adjudication.

The range of motion (ROM) evaluations in evidence 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)	MEB ~4 Mos. Pre-Sep
	VA C&P ~1 Mos. Post-Sep
	
Flexion (140 Normal)	105	120	
Extension (0 Normal)	2 HE	0	
Comment	Decreased ROM and painful motion 	Tenderness and guarding of movement	
§4.71a Rating	10%	10%	

At the MEB NARSUM examination on 2 April 2008, 4 months before separation, the CI reported pain in the middle of her kneecap with trouble "climbing stairs, squatting, picking up stuff, bending and sitting for a long time (3 hours)."  The physical examination showed an antalgic gait favoring the right and difficulty with toe and heel walking due to right knee pain.  There was “functional ROM of bilateral knees” as noted in the chart above, without evidence of any laxity or instability and “pain was noted with flexion and with patellar grind and apprehension on the right only.”  There was no effusion present.  Sensation and strength were intact, except for decreased “give-way” strength with extension due to pain.  “

At the time of the MEB physical therapy ROM study on 9 April 2008, 4 months before separation the examiner noted decreased ROM and painful motion indicated in the chart above.  The knee showed no instability. 

At the VA Compensation and Pension (C&P) examination on 30 September 2008, performed 1 month after separation, the CI reported weakness, stiffness, swelling, giving way and locking and denied lack of endurance, fatigability or dislocation of the right knee.  She reported constant pain in the right knee and use of a brace for “weakness and instability.”  She reported she could not sit for a long period of time and could not run or jump.  Physical examination of the right knee showed a limp “favoring the right knee.”  There was tenderness and guarding of movement but there were no signs of edema, effusion, weakness, redness and heat.  There was slight instability of the medial and lateral ligaments.  Knee ROM was as recorded in the chart above.  There was no anterior or posterior instability or subluxation.  The “medial and lateral meniscus test…is abnormal with slight degree of severity.”  Right lower extremity strength, sensation, and reflexes were normal.  Right knee X-rays were normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the right knee condition 10%, coded 5099-5003 (analogous to degenerative Arthritis), citing painful motion.  The VA rated the right knee condition coded 5260 (limitation of flexion) citing painful or limited motion of a major joint with evidence of arthritis.  The VA also rated the right knee condition 10%, coded 5257, (other impairment of the knee) citing recurrent slight lateral instability of the knee.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261); however, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  Although the VA rated the right knee 10% for painful motion and 10% for instability, there was no evidence of knee laxity or instability at the MEB NARSUM examination or evaluations in the STR, including two different orthopedic consults.  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and member consensus was that there was insufficient grounds for additional rating based on the presence of instability.  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 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.  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 20140218, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160009933 (PD201400844)

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