RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00883
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Military Police, medically separated for “right knee pain…” with a disability rating of 10%.

CI CONTENTION:  Attempts at non-surgical and surgical treatments with no improvement.  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 - 20090819	VARD - 20100322	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	Patellofemoral Syndrome with Osgood Schlatter’s Syndrome, Right Knee	5260	20%	20091022	
Generalized Anxiety Disorder	Meets Medical Retention Standards	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Right Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain condition began in May 2008 after a six mile company run when he felt his knee buckle.  An MRI showed tendinopathy and small partial tear.  At the Medical Evaluation Board (MEB) examination (recorded on DD Forms 2807 and 2808) dated July 2009, 2 months before separation, the CI reported edema, erythema, and effusion on both knees and discomfort on flexion and tenderness to palpation (TTP).  The physical examination confirmed the CI’s reported symptoms.

At the VA Compensation and Pension (C&P) examination in October 2009, performed a month after separation, the CI reported he had problems with running and marching and a poor outcome with physical therapy.  Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) yielded poor results; however, the use of Indocin (Indomethacin, an NSAID) did not alleviate his pain, but did help to reduce swelling of the knee.  The CI rated his pain level at 4-5/10 at rest and the pain became progressively worse with inclined surfaces and climbing.  Physical examination revealed swelling, effusion and tenderness and a joint abnormality was noted to be consistent with Osgood Schlatter’s Syndrome (inflammation of the patellar ligament at the tibial tuberosity).  On examination, there was an antalgic gait, crepitus, tenderness, grinding and no instability.  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 “chronic right knee patella-femoral syndrome & patellar tendonitis...” for PEB adjudication.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the analogous 5099-5003 code (analogous for arthritis, degenerative) for right knee pain resulting from patella-femoral syndrome and patellar tendonitis citing right patellar grind and mild tenderness.  The VA assigned a 20% rating using the code 5260 (leg limitation of flexion) for patellofemoral syndrome with Osgood Schlatter’s Syndrome, right knee. 

The Board agreed there was evidence of painful motion with the noncompensable flexion ROMs, which supported a 10% rating based on VASRD §4.59 (painful motion), §4.40 (functional loss) and §4.45 (the joints).  However, there was limitation of extension of 15 degrees, 2 months prior to separation, which supports a 20% rating coded 5261.  This was followed by a 5 degree limitation of extension, a month after separation, which warrants a 0% rating.  The Board next deliberated the VA examination’s 30 degrees limitation of flexion after repetition which warrants a 20% rating.  Board members discussed whether this measurement was either an actual finding or typo since it was so disparate from the other flexion measurements.  The Board concluded this finding was a typo.  The probative value of each examination was discussed and weighed by the Board members.  Both MEB and the VA examinations noted limited flexion and extension supported by findings of painful motion without instability, code 5257.

The Board also reviewed codes 5258 and 5259 (cartilage, semilunar, dislocation, locking; or removal of, symptomatic) but determined they were not applicable to this case.  Additionally, 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).  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 pain condition.

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the generalized anxiety disorder was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The generalized anxiety disorder condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.

A note dated 7 July 2009 indicated the CI had been seen a year earlier for symptoms of anxiety, which were significantly worse during a time of marital discord.  Supportive therapy was carried out and since that time he and his wife decided to separate.  As a result the CI reported less symptoms.  Episodically he endorsed some anxiety, but was able to cope using behavioral/breathing exercises.  He denied symptoms of depression or any manic or psychotic symptoms.  A mental status examination revealed a well-groomed CI with good eye contact, speech fluent with a normal rate/tone/prosody (patterns of stress and intonation in a language), with no psychomotor slowing or agitation.  His mood was “alright” and his affect was full range and appropriate.  He denied suicidal or homicidal ideation, auditory or verbal hallucinations and his thought process was logical, and liner, coherent, and goal directed.  He had been off medication, sertraline (an antidepressant), for over a year and did well overall with episodic anxiety symptoms that he did cope with cognitively and behaviorally.

The Board considered whether application of VASRD §4.129 was applicable since the mental health condition did not result from a highly stressful event of a physical or mental traumatic nature severe enough to bring about her release from service.  Therefore, the Board determined that application of VASRD §4.129 is not warranted.

The aforementioned was reviewed and considered by the Board.  There was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance at separation.  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 generalized anxiety disorder and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended general anxiety disorder 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.  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, 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, AR20160007263 (PD201400883)

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