RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01075
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20090617

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Multichannel Transmission System Operator-Maintainer, medically separated for “chronic left knee pain,” with a disability rating of 10%.

CI CONTENTION:  “Due to the chronic pain of my left knee and the daily pain medications causes me to not be able to work in my preferred field of work…. As well as other service connected disabilities such as my constant migraines and anxiety and insomnia from PTSD makes holding and keeping a job nearly impossible.” 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 Veteran’s Affairs (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 - 20090226	VARD - 20091205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Degenerative Arthritis, S/P Medical Meniscus Repair, Left Knee	5010	10%	20090508	
			Left Knee Surgical Scar	7805	0%	20090508	
Migraine Headaches	Not Unfitting	Migraines	8100	30%	20090508	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in 1997.  He underwent surgery for anterior cruciate ligament (ACL) repair.  Following the surgery he was on a P2 profile for years and did well.  In 2007 the CI developed more problems with his knee and underwent a second ACL surgery in April 2007.  Following the 2007 surgery, the CI reported there was no change in his chronic knee pain.  He was treated for arthritis of the knee with multiple injections.  Left knee magnetic resonance imaging (MRI) in April 2008 noted degenerative changes of the knee, possible medial meniscal tear, and an intact ACL graft.  Left knee X-rays noted a density near the inferior patella, possibly calcification of a ligament or tendon.  At the orthopedic evaluation on 26 August 2008, the examination showed no tenderness to palpation, no effusion, and patellar grind was negative.  There was no evidence of instability or meniscal pathology and there was full range of motion (ROM) of the knee.  Despite treatment, the left 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 left knee pain” for PEB adjudication.

At the MEB NARSUM examination on 12 January 2009, the CI reported chronic left knee pain which was aggravated by all exertional type activities.  He reported using acetaminophen (Tylenol) and occasional narcotic pain medication for the knee pain.  On physical examination there was a normal gait.  There was “mild” tenderness of the joint line at the front of the knee, without effusion, negative patellar compression test, and normal tracking of the patella.  There was no evidence of instability or meniscal pathology.  Knee ROM was flexion 130 degrees (normal 140 degrees) and extension 0 degrees.  Strength, sensation, and reflexes of the leg were normal.  The MEB NARSUM examiner indicated that the CI “put in a full-duty day” working light detail around the company area and was engaged in attending college, with physical limitations regarding “exertional components,” but noted “if he simply does clerical duties, he is good to go.”

At the 8 May 2009 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported constant left knee pain with weakness, stiffness, swelling, giving way, and locking, but no dislocations.  He reported the pain was relieved by rest and pain medication and that at the time of the pain he could function with medication.  The physical examination noted a normal gait.  There was knee tenderness and crepitus.  There was no effusion, guarding, subluxation or evidence of instability or meniscal pathology.  Knee ROM was flexion 130 degrees and extension 0 degrees, with pain.  There was no additional loss of ROM with repetition.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing painful limitation of motion in one major joint.  The VA also rated the knee condition 10%, coded 5010 (traumatic arthritis), citing painful limitation of motion.

There was evidence of degenerative joint changes and limited motion supporting a 10% rating coded according to 5003 rating criteria as adjudicated by the PEB.  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  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).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 adjudication for the left knee condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended migraine headaches condition 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 commander’s statement dated 18 November 2008 did not specify any individual medical conditions, but noted “medical condition” (singular), and also noted the CI was unable to work an 8-hour duty day “due to medical condition.”  The permanent P2U2L3 profile listed “left knee, low back pain, migraine headaches, hypertension, right shoulder pain, and hypertension.”

The migraine headaches condition was given a permanent P2 profile.  A profile designation of “2” indicates a condition which requires some physical limitations, but is not in all cases disqualifying for continued military service.  The commander’s statement did not specifically implicate the migraine HAs and implied the CI was unable to perform his full duties due to a single medical condition.  The record is clear that the CI was referred for an MEB due to the left knee condition.  There was no performance based evidence from the record that the migraine headaches significantly interfered with satisfactory duty performance.  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 contended migraine headaches and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the chronic left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine headaches 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, 20140223, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160009951 (PD201401075)

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