RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00946
BRANCH OF SERVICE:  Army	BOARD DATE:  20150603
SEPARATION DATE:  20080712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Health Care Specialist) medically separated for left knee pain.  The left knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Chronic left knee pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition, “mild elevation of triglycerides,” for PEB adjudication.  The Informal PEB (IPEB) adjudicated “left knee pain” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  At a later date, a PEB Administrative Correction was issued, but maintained the same conditions and ratings.

CI CONTENTION:  “I was given 10% due to left knee arthroscopic synovectomy and not due to the degenerative arthritis. I have not had an evaluation or appointment since 2008.  The Leavenworth VA told me they would make an appointment and never did.”

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:

 Admin Corr PEB – Dated 20080416	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	10%	Status Post Left Knee Arthroscopic Synovectomy	5260-5024	10%	20080623	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20080903 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board notes for the record that IAW VASRD 4.71a and 4.14 (avoidance of pyramiding), arthroscopic synovectomy and arthritis cannot be rated separately, and that rating of either condition will subsume the symptoms of the other.

Left Knee Condition.  The narrative summary (NARSUM) and service treatment record detailed that the CI had the onset of left knee pain in August 2006 (2 years prior to separation), the day after doing jumping jacks, without any specific traumatic injury.  He was referred for physical therapy, “which did not help.”  He felt a pop in his knee when running 3 months later, and had imaging (X-rays and magnetic resonance imagings) reported to be normal by the radiologist.  He was referred to orthopedics and had surgery in April 2007 (15 months prior to separation).  Examination under anesthesia demonstrated a stable knee exam with a negative pivot and a negative Lachman with no effusion (both tests evaluate the anterior cruciate ligament [ACL]); while arthroscopy showed no chondral (bony cartilage) defect, intact ACL, no meniscal tears, minimal fraying on the white-white edge of both menisci, and abundant hyperemic synovium anteriorly (which was excised).  The CI’s symptoms returned when he resumed physical activities, and he felt another “pop” in the knee in September 2007.  The orthopedist stated that surgery was again an option, but that “the odds are low of that showing anything” (per the CI), and he declined a second procedure.

On examination on 9 October 2007 (6 months after surgery and 9 months prior to separation), the orthopedic surgeon noted normal gait and strength, and no laxity:  no medial or lateral instability, no anterior drawer sign (testing the ACL), and no posterior drawer sign (testing the posterior cruciate ligament).  On 28 January 2008 (6 months prior to separation), the CI reported no sudden “lock up,” no feeling of instability, and no sudden buckling.  On examination, the surgeon noted crepitus of the knee, positive McMurray test (suggestive of a meniscus tear), negative posterior drawer sign, and a negative anterior drawer sign.  A Lachman test was negative, while there was “Anterolateral rotary instability with no active pivot shift.”

On the DD Form 2807-1, Report of Medical History, dated 28 January 2008 (6 months prior to separation) the CI reported “pain, buckling when walking up or down stairs, painful to bear weight for long periods of time ….”  The accompanying examination (DD Form 2808, Report of Medical Examination) described the lower extremities as “normal.”

At the NARSUM evaluation on 26 February 2008 (5 months prior to separation), the CI reported pain “40% to 45% at time” while he was awake.  The CI reported no swelling, locking, or instability; although he described some subjective give way secondary to pain that occurred on a daily basis when he went up and down stairs.  On examination, gait was normal, active and passive range-of-motion (ROM) of both knees was 130 degrees (normal 0 to 140), and there was no effusion or muscle atrophy.

The VA Compensation and Pension exam was performed on 23 June 2008 (a month prior to separation).  The CI noted problems with squatting, kneeling, crawling, prolonged driving, and going up or down stairs.  He had no locking or giving way of the knee.  He used a Neoprene type of brace as needed.  On examination, there was no laxity or instability of the knee joint; mild (1+) coarse crepitation was noted.  Range-of-motion was 0 to 135 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB rated the condition at 10%, analogously coded 5003 (degenerative arthritis), citing painful motion.  The VA rated the condition at 10%, analogously coded 5260-5024 (limitation of flexion of leg – tenosynovitis).  The VASRD states that code 5024 will be rated on limitation of motion as degenerative arthritis (code 5003).  Although the NARSUM and VA exams both annotated decreased ROM, it was not compensable under the applicable knee and leg codes.  However, both examinations supported a rating of 10% under codes 5003 and 5024 based on limitation of motion or painful motion.  Although the CI mentioned some subjective give way secondary to pain in the NARSUM, there was no history of this on the orthopedics exam on 28 January 2008 or the VA exam.  Surgery demonstrated intact structures in the knee and no laxity in the examination under anesthesia, and the CI had no history of subsequent traumatic injuries.  The VA exam demonstrated no laxity on clinical examination, and no specific test in the orthopedics examination demonstrated any laxity.  There was not a pathway to a higher rating based on ankylosis; subluxation or lateral instability; frequent episodes of “locking,” pain, and effusion into the joint; ROM; or impairment of the tibia and fibula.  Neither meniscus (semilunar cartilage) was removed in surgery, and rating the knee symptoms analogously under this condition (code 5259) would not result in a higher rating.  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 left 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 left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.

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 20140224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX 
President 
DoD Physical Disability Board of Review

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, AR20150015755 (PD201400946)

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:

Encl						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA