RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00926
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080507

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Tracked Vehicle Mechanic) 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) and 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 “lateral meniscus tear right knee” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated “right knee lateral meniscus tear” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contends for a higher rating for his unfitting condition and asks for consideration of a condition not identified by the MEB or PEB.  The applicant’s 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:  

IPEB - Dated 20080411	VA* -  based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Lateral Meniscus Tear	5099-5003	10%	Right Knee Meniscus Tear	5260-5010	0%**	STRs	
Other MEB/PEB Conditions x 5 (Not In Scope)	Other x 6	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20081017 (most proximate to date of separation [DOS]).  **VARD dated 20100830 increased rating for knee to 10% effective DOS

ANALYSIS SUMMARY:  

Right Knee Lateral Meniscus Tear.  The earliest note in the service treatment record (STR) dated 15 August 2005, indicated the CI heard and felt a pop when tripping over a pothole.  The original assessment was a contusion of the right knee and treatment consisted of the RICE (rest, ice, compression, and elevation) protocol along with a nonsteroidal anti-inflammatory drug (NSAID) and no running for 10-14 days.  An X-ray series on the same day was normal, but magnetic resonance imaging (MRI) of the right knee, dated 24 August 2005, showed medial and lateral meniscus tears, extensive bone marrow edema/contusion in the medial femoral and tibial condyles with occult or micro fracture of the proximal tibia and extensive soft tissue edema with joint effusion.  Further history revealed the CI had right knee pain episodically for 3 years after he injured his knee in a fall.  The CI had declined a recommended arthroscopy because he wanted to deploy and tried rest, NSAIDs, and physical therapy off and on for 3 years without relief.  X-rays of the right knee in September 2005 demonstrated a moderately large joint effusion without other significant findings; follow-up X-rays in October 2005 were normal.  By December 2005, the CI was feeling better, but was recommended for a P3 profile for right knee patellofemoral syndrome.  An X-ray series of the right knee was normal on 30 May 2006.  At a physical therapy session in July 2006, the CI had tenderness on palpation of the knee with pain on Noble’s compression test (to determine an iliotibial band friction syndrome) and a positive McMurray’s test (to determine a meniscal tear) without instability.  At an orthopedic evaluation in August 2006, the CI complained of diffuse right knee pain.  On examination, there was no effusion; the range-of-motion (ROM) was -10 to 140 degrees without instability, but with an exquisitely painful patellar grind, mild medial and lateral joint line tenderness, and tenderness to palpation at the patellar tendon.  An MRI, dated 21 February 2007, revealed a small tear of the posterior horn of the medial meniscus of the right knee.  The previously noted tear of the lateral meniscus in 2005 was not identified nor was the bone marrow edema or effusion.  On 13 April 2007, the CI underwent a right knee arthroscopy with lateral release, medial plicectomy (removal of a portion of a thickened band of joint covering), and debridement of slight changes to anterolateral horn of the [medial] meniscus; but there appeared to be some healing undersurface tearing of the medial meniscus, which was not treated.  Postoperatively, a knee immobilizer was placed.  A physical therapist in May 2007 noted a mild effusion in the right knee with abnormal motion of 5 HE (hyperextension) to 120 degrees limited by pain; there was no resistance through the motion, although the CI subjectively complained of knee motility issues with locking.  At the orthopedic evaluations in July 2007 and September 2007, the CI stated his pain was really not much different than prior to surgery.  The ROM was 0-135 degrees with good patella mobility and there was quadriceps atrophy and weakness.  Physical therapy ROM measurements on 11 March 2008 were for flexion of 120 degrees and extension of 0 degrees.  Lachman’s test (to determine instability) was 2 A (solid end feel) for the right as well as the left knee.   

The commander’s statement, on 28 November 2007, indicated the CI was incapable of performing his duties as a tracked vehicle mechanic, which involved constant kneeling and individual movement techniques.  At the MEB examination dated 29 November 2007, the CI reported on DD Form 2807-1, Report of Medical History, right knee surgery that still hurt.  On 3 December 2007, the MEB physical examiner noted on DD Form 2808, Report of Medical Examination, right knee tenderness to palpation at the bilateral joint lines and all around the patella with crepitus and tenderness to pressure in the popliteal region (in the back of the knee).   A permanent L3 profile was issued on 18 December 2007 for right knee continued pain and disability following surgery with limitations of all military functional activities with the exception of wearing a protective mask and all chemical defense equipment.  Additional limitations included no squatting, no running, no prolonged walking greater than 3 miles, no prolonged standing greater than 60 minutes and avoiding stairs, if possible.

The MEB narrative summary (NARSUM), dated 20 February 2008, noted the CI’s right knee pain began in the winter of 2001 when he fell thirty feet on a hard surface while working on the boom of a stationary vehicle.  He responded, but incompletely, to conservative treatment allowing him to continue military duties with some profile restrictions. After arthroscopic surgery in April 2007, the CI described the pain as if “someone is driving a chisel into my knee” and at the time of the NARSUM rated the constant pain at a level of 5/10 (10 being the worst pain).  Participation in any high impact activities augmented the pain to 9/10 with a prolonged recovery time.  On examination there was no palpable effusion and movement of the knee in any direction resulted in pain.  Lachman’s sign (to test for laxity) and McMurray’s sign (to test for a meniscal tear) were negative, but there was an increase ROM to varus and valgus testing (to determine laxity) as well as extension of the leg at the knee.  Patellar testing was unremarkable.  Because of the pain and functional loss resulting from the right knee injury, the CI assumed a sedentary lifestyle and was unable to perform his duties.

The VA Compensation and Pension (C&P) initially scheduled examination was not performed; however, a follow-up C&P examination was performed on 16 January 2009, approximately 8 months post-separation.  The examiner noted that the right knee was normal in appearance, but the CI had pain on repeated use; there was no fatigue, weakness, incoordination, and no additional loss of motion or function, but he had lack of endurance due to pain on repetitive use.  There was no objective evidence of edema, effusion, instability, weakness, redness, abnormal movement or guarding of movement.  He had tenderness over the inferior patellar tendon and on patellar compression.  The ROM measurements were flexion 0-140 degrees with pain between 90-140 degrees and full extension to 0 degrees.
  
The 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)	PT ~2 Mo. Pre-Sep
	VA C&P ~8 Mo. Post-Sep
	
Flexion (140 Normal)	120/120/120/120	140	
Extension (0 Normal)	0/0/0/0	0	
Comment	Lachman’s 2 A	Pain between 90-140 degrees; lack of endurance due to pain on repetition	
§4.71a Rating	PEB 10%	10% (VA 0% initially)	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5003 (degenerative arthritis) for the right knee lateral meniscus tear.  The VA initially assigned a 0% rating using code 5260-5010 (leg limitation of flexion-arthritis due to trauma substantiated by X-ray findings) for the right knee meniscus repair based on the STR, but revised the rating to 10% on 30 August 2010 retroactive to the day after separation.  The Board sought a route to a higher rating.  However, in the absence of ankylosis, recurrent subluxation or lateral instability, meniscal dislocation with frequent episodes of “locking,” pain (although the CI had constant pain), and effusion into the joint, a more limited ROM, tibia and fibula impairment, or genu recurvatum, the Board was unable to find a route to a higher rating.  The CI did have debridement of a meniscus raising the use of code 5259 (cartilage, semilunar removal, symptomatic) with a rating of 10%, which is more precise than 5099-5003, but its use in combination with 5099-5003 raises a pyramiding issue, which IAW VASRD §4.14 is to be avoided.  Therefore, 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 lateral meniscus tear 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 lateral meniscus tear 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 20140221, 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, AR20160002407 (PD201400926)

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