RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01036
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080709

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-3 (Artillery Officer) medically separated for bilateral knee osteoarthritis.  The condition could not be adequately rehabilitated to meet the physical requirements of his Area of Concentration (AOC).  He was issued a permanent P2 L3 profile and referred for a Medical Evaluation Board (MEB).  The “bilateral knee osteoarthritis with tri-compartmental degenerative changes, left worse than right,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded twelve other conditions (hypertension; erectile dysfunction [ED]; pre-diabetes; left hand ring finger proximal interphalangeal [PIP] flexion deformity; bilateral plantar fasciitis; tinnitus; nightmares; attention deficit hyperactivity disorder [ADHD]; mild to moderate, REM predominant, obstructive sleep apnea [OSA]; right lateral epicondylitis; hyperlipidemia) for PEB adjudication.  The Informal PEB adjudicated “bilateral knee osteoarthritis” as unfitting, rated 10% each.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated. 

CI CONTENTION:  The applicant asks that PTSD with sleep apnea, ADHD, scars, hypertension, plantar fasciitis, chest pain, left shoulder, bilateral elbows and bilateral wrists, and left hand conditions be considered.  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 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:  

IPEB - Dated 20080311	VA* - (~1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Osteoarthritis…	5003	10%	Right Knee Strain	5260	10%	20080605	
			Scar Status Post Arthroscopy Right Knee	7805	0%	20080605	
Left Knee Osteoarthritis…	5003	10%	Left Knee Strain Status Post ACL Repair	5260	10%	20080605	
			Scar Status Post Arthroscopy Left Knee	7805	0%	20080605	
Hypertension	Not Unfitting	Hypertension	7101	0%	20080605	
Left Hand Ring Finger PIP Flexion Deformity	Not Unfitting	Left Fourth Finger Flexion Deformity	5230	0%	20080605	
Bilateral Plantar Fasciitis	Not Unfitting	Bilateral Plantar Fasciitis	5284	0%	20080605	
Nightmares	Not Unfitting	PTSD	9411	30%	20080618	
ADHD	Not Unfitting					
Mild To Moderate … OSA	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20080605	
Right Lateral Epicondylitis	Not Unfitting	Bilateral Tennis Elbow and Right Lateral Epicondylitis	5206	NSC	20080605	
Other MEB/PEB Conditions x 5	Other x 10	
RATING:  20%	RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20081106 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Right Knee Osteoarthritis.  The first record in evidence was a primary care note dated 18 March 2005 for left knee pain.  However, the CI also noted right knee pain and was thought to have inflammation of the lining of the joint.  He was treated with duty restrictions and physical therapy (PT), but his pain persisted.  He was then evaluated in orthopedics and noted to have improvement (although the left knee pain persisted).  X-rays on 24 January 2006 showed mild osteoarthritis (OA) of the right knee.  In primary care on 7 June 2007, he reported bilateral knee pain for ten years since basic training.  He was noted to have full but painful motion.  In orthopedics on 2 July 2007 he demonstrated no distress as he walked from the waiting room to the examination room.  The range-of-motion (ROM) was reduced to 120 degrees of flexion, but the knee was stable and had no signs of meniscal (internal cartilage cushions) irritation.  In Sports Medicine a month later, he had a similar examination.  He was treated with a knee brace.  He initially had surgery of the left knee (below) and then had surgery on the right.  A pre-operative evaluation on 3 October 2007 noted that flexion remained 120 degrees and instability was absent.  An MRI noted a medial meniscus tear (MMT) and degeneration of the joint and the kneecap cartilage lining.  These were repaired at surgery on 26 October 2007, 8 months prior to separation.  On examination under anesthesia (EUA), he had no effusion and a stable joint.  In PT on 7 November 2007, he was noted to have a slow and steady gait, could do a full squat with mild pain, and climb one flight of stairs.  A trace effusion was present (normal less than 2 weeks after surgery) and flexion was 125 degrees.  The narrative summary (NARSUM) dated 20 November 2007 noted that the onset of the right knee pain was in 1999.  He ambulated easily from the waiting room.  On examination, he had no effusion and a stable knee.  He was tender on both the lateral and medial joint line.  Flexion was reduced as noted below.  At the VA Compensation and Pension (C&P) examination performed on 5 June 2008, one month before separation, the CI reported difficulty with climbing stairs and prolonged sitting, walking, or bending.  He reported difficulty with taking out the trash and pushing a lawnmower.  The surgical scars were non-disfiguring and were non-tender.  His gait and posture were normal.  The ROM was reduced as charted below and limited by pain.  The knee was stable and without signs of meniscal irritation.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation for both knees, with documentation of additional ratable criteria, are summarized in the chart below.

Knee ROM
(Degrees)	MEB ~7 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	125	125	100	110	
Extension (0 Normal)	0	0	0	0	
Comment	Not limited by pain	Limited by pain	
§4.71a Rating	0%	0%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The ROM was not compensable and there was not instability to support an additional rating.  Painful motion was documented on the VA examination, supporting a 10% rating, but not on the PEB examination.  The PEB rated the right knee at 10%, coded 5003 (degenerative arthritis).  The VA also rated the knee at 10%, but coded 5260 (limitation of flexion).  The Board found no route to a higher rating for the right knee.  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.  

Left Knee Osteoarthritis.  The record shows that the CI first noted left knee pain in 1997 and was treated conservatively for it initially as he was for the right knee.  In orthopedics, he was thought to have anterior cruciate ligament (ACL) deficiency and arthritis of the joint.  An MRI on 29 July 2007 was significant for a MMT as well as a complete tear of the ACL.  When seen in sports medicine by the same orthopedist on 6 August 2007, the ACL deficiency was no longer apparent.  He had surgery on 6 September 2007 and was found to have a MMT and cartilage degeneration which was repaired.  The ACL appeared normal and was stable to examination.  He then had rehabilitation prior and subsequent to the surgery on the right knee.  The NARSUM noted a stable knee without effusion.  He did have some testing suggestive of ACL laxity (trace Lachman and pivot glide), but as noted above, the ACL appeared normal when visualized at surgery and testing was normal at that time.  Flexion was limited to 125 degrees, but pain free.  At the VA C&P examination performed, the CI had a normal gait and painful, limited flexion as charted above.  The knee was stable to examination.  Signs of meniscal irritation were absent.  

The Board directed attention to its rating recommendation based on the above evidence.  The ROM was not compensable and there was not instability to support an additional rating.  Painful motion was documented on the VA examination, supporting a 10% rating, but not on the PEB examination.  The PEB rated the left knee at 10%, coded 5003 (degenerative arthritis).  The VA also rated the knee at 10%, but coded 5260 (limitation of flexion).  The Board found no route to a higher rating for the left knee.  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

Contended PEB Conditions.  The hypertension, left ring finger, bilateral plantar fasciitis, nightmare, right lateral epicondylitis, OSA, and ADHD were both contended by the CI and considered in the PEB process.  The Board’s main charge is to assess the fairness of the PEB’s determination that these conditions were 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.  Of these, only the bilateral plantar fasciitis and OSA were profiled at the time of separation.  Only the unfitting knee pain was implicated in the commander’s statement.  None of the conditions was judged to fail retention standards.  The OSA was mild and treated with CPAP (continuous positive airway pressure).  The plantar fasciitis condition was adequately treated with orthotics.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at the time of separation.  After due deliberation 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 any of the contended conditions and so no additional disability ratings are recommended.
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 and left knee osteoarthritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension, left ring finger, bilateral plantar fasciitis, nightmare, right lateral epicondylitis, OSA, and ADHD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  

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 20140226, 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, AR20160002572 (PD201401036)

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