RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00885
BRANCH OF SERVICE:  Army	BOARD DATE:  20150217
SEPARATION DATE:  20081113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Track Vehicle Repairer) medically separated for a right knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The profile allowed for an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right knee condition, characterized as “chronic posterior cruciate ligament strain, right knee” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “posterior cruciate ligament strain” as unfitting, rated 10% citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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:

Service IPEB – Dated 20081020	VA - (10 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posterior Cruciate Ligament Strain, R Knee	5099-5003	10%	Internal Derangement of the Right Knee	5299-5260	10%	20090928	
Other x 0 (Not in Scope)	Other x 3	
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20091105 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Posterior Cruciate Ligament Strain, Right Knee.  Review of the service treatment record (STR) indicated that the CI had some right knee pain prior to service and was diagnosed with meniscal (cartilage) pathology, without further delineation.  He was seen in primary care on 8 February 2008 for “pain to the right knee pain x2 days after PT [physical training]”; this was associated with either doing lateral exercises or falling during unit PT.  The CI stated that his pain was worse that morning, and that his knee “went out to the side” with every maneuver of side-straddle hop.  The knee was tender diffusely, pain was elicited with movement in all directions, and no laxity or crepitus (grating) was noted.  Conservative treatment with temporary profiles, pain medication, and physical therapy did not help.  An x-ray and a magnetic resonance imaging (MRI) scan of the right knee in April 2008 were both normal.  The MRI specifically reported all ligaments (anterior and posterior cruciate ligaments and medial and lateral collateral ligaments) were intact and normal without any abnormal signal to suggest injury or strain.  A clinic examination on 30 June 2008, recorded negative drawer signs (for instability) and a normal gait.  The CI was seen in the emergency room (ER) on 14 August 2008, and an X-ray was done of the right knee (normal), but the ER note is not in the STR.  At a physical therapy evaluation on 5 August 2008 the CI had antalgic gait with full extension to 0 degrees and flexion of 120 degrees (normal 0 to 140) with “pain at end ranges.”  At a physical therapy evaluation on 22 August 2008, after 3 weeks of therapy and 3 months prior to separation, the CI complained of pain rated at 4/10, no locking or giving way, and inability to stand on one leg secondary to pain and feeling of giving way.  On examination he stood with his right knee flexed and was very hesitant to extend it, was able to ambulate normally, and had “full ROM” with “pain at end ranges.”  At an orthopedic examination on 8 September 2008 (2 months prior to separation) the CI had normal gait, quadriceps muscle atrophy but no muscle weakness, crepitus (grating) and tenderness of the patella (kneecap), and medial joint line tenderness.  Although the examiner noted “laxity of the knee,” later in the examination he specified that tests for instability were negative (negative anterior drawer, negative posterior drawer, no lateral instability, no medial instability).  The final diagnosis was “knee sprain cruciate ligament posterior,” a permanent profile was issued, and an MEB was recommended.  The MEB exam a week later (on 15 September 2008) detailed, “Knee pain, giving out, July 15, 2008, treated/ treatment in process (MEB) …”

The MEB physical exam (a week later) noted limited flexion and extension of the knee, tenderness to palpation of the medical joint line, no effusion, no laxity, and pain with McMurray test (done to evaluate for potential meniscus cartilage tears, but a positive test involves a palpable click, not just pain).  Range-of-motion (ROM) examination by physical therapy on 16 September 2008 was extension 20 degrees (normal 0) and flexion 90 degrees (normal 140), with painful motion on both flexion and extension.  The examiner stated, “ROM was limited by pain, but did not appear to be limited by fatigue, weakness, lack of endurance or incoordination,” and “patient demonstrated increased muscle guarding secondary to pain during both extension and flexion ROM to right knee.”  At the narrative summary (NARSUM) examination a few days later on 19 September 2008, there was marked guarding of the right knee, no effusion, a 1A Lachman test, “no evidence of laxity,” evidence of quadriceps muscle atrophy (15.25 inches on the left vs. 14.25 inches on the right), and normal gait.  The examiner stated, “It was very difficult to ascertain motor muscle strength as service-member appeared to show exaggerated expression of pain on active and passive resistance with extension and flexion of the right knee.”  At the VA Compensation and Pension exam performed on 28 September 2008, 10 months after separation, the CI reported that he had right knee arthroscopy (surgery by scope) in March 2009 (4 months after separation).  He went back to work but fell and injured his right knee again, and faced potential repeat arthroscopy.  On examination he had extension of 0 degrees (normal) and flexion 110 degrees (normal 140) after repetitive motion, tenderness in the patellar area, and positive crepitus.  There was no evidence of anterior or posterior laxity but “varus and valgus stress of the left knee was … abnormal on the right with pain demonstrated laterally and medially and in the patellar area,” and “… McMurray test … demonstrated internal derangement and pain on the right knee.”  An X-ray of the right knee was reported as normal.  The diagnosis was internal derangement of the right knee and decreased range of motion of the right knee.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10% under analogous code 5003 (degenerative arthritis), citing painful motion and stating that the posterior cruciate ligament strain caused chronic knee pain, analogous to degenerative arthritis, with no mechanical instability or compensable loss of motion that would be evaluated under a different code.  The VA characterized the condition as internal derangement of the right knee and rated the condition analogous to code 5260 (Limitation of flexion of leg) at 10%, citing painful or limited ROM.  The Board found the VA examination to be of limited probative value because it was performed 10 months after separation and the CI had arthroscopic surgery in the interim.  The CI had several examinations relatively close to the DOS.  The Board noted the CI’s complaints of his “knee going out” and his knee going “out to the side” with side-straddle hops.  Although the CI had some tenderness of the patella on palpation, there was no evidence of patellar or collateral (right or left side) ligament laxity in any examination that could account for significant subluxation (of the patella) or lateral instability (of the collateral ligaments).

At the NARSUM examination the CI was noted to have a 1A Lachman test, which would correspond to mild subluxation, but the examiner also stated that, “there was no evidence of laxity.”  The MEB exam specifically detailed no laxity of the anterior cruciate ligament, and the orthopedic exam specifically detailed no lateral or medial instability and specific tests of the anterior and posterior cruciate ligaments were negative for instability.  In view of the normal MRI imaging tests and minimal findings on physical exams, the Board found that the STR did not support recurrent subluxation, lateral instability, or symptomatic semilunar cartilage (meniscus) to be a ratable condition.

The Board noted “full ROM” with painful motion on the physical therapy evaluation on 22 August 2008.  The MEB, NARSUM, and orthopedic exams did not address specific ROM of the knee, while the physical therapy exam on 16 September 2008 noted flexion 90 degrees (normal 140) and extension 20 degrees (normal 0).  The Board did not find this degree of loss of extension to be consistent with other exams, including annotations of normal gait 8 days prior to and 3 days after this exam.  The Board concluded that the CI had painful motion that was ratable under §4.59 (painful motion), but that the STR did not support a compensable (i.e., higher) rating under §4.71a and codes 5260, 5261 (limitation of extension of leg), or 5262 (Impairment of tibia and fibula).  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:  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 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.

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 20140214, 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 XXXXXXXXXXXXXXXXXXXXX, AR20150019010 (PD201400885)

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