RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01213
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090811

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “right persistent knee pain (healed stress fracture)” and “left persistent knee pain (healed stress fracture),” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Knee pain causes me to compensate leading to other complications such as tendonitis in my femur.  Knee pain lead me to sit most of the day, contributing to a cyst that led to a chronic wound.”  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 based upon a 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:  

SERVICE PEB - 20090731	VARD - 20100702	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Persistent Knee Pain (Healed Stress Fracture)	5099-5003	10%	Right Knee Pain, Residual of Healed Tibial Stress Fracture	5299-5262	10%	20100327	
Left Persistent Knee Pain (Healed Stress Fracture)	5099-5003	10%	Left Knee Pain, Residual of Healed Tibial Stress Fracture	5299-5262	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 2 0%	

ANALYSIS SUMMARY:  

Right Persistent Knee Pain (Healed Stress Fracture).  According to the Medical Evaluation Board (MEB) narrative summary (NARSUM) and service treatment records (STR), in January 2009, the CI was diagnosed with a stress fracture of the medial tibial plateau of the right knee.  He was treated with medication, physical therapy (PT), and other therapeutic measures.  In spite of all treatment efforts, his knee pain persisted and an MEB was initiated.  The MEB NARSUM was dated 7 July 2009.  On physical examination (PE) of the knees, there was no effusion, swelling, or ecchymosis.  Range of motion (ROM) was full.  Neurological examination (sensory and motor) was normal.  The knees were nontender to palpation, and all tests for ligamentous laxity were negative.  The examiner wrote: “The service member does not have any objective physical findings at this time.  His pain is largely subjective in nature.”

The CI was medically separated from service on 11 August 2009.  Seven months later, in March 2010, he had a VA Compensation and Pension (C&P) examination.  On PE, posture and gait were normal.  PE of the knees revealed pain with motion.  The examiner wrote: “mild dysfunction due to pain.” The ROM evaluations in evidence which the Board weighed in arriving at its recommendation, are summarized in the chart below.

Right Knee ROM
(Degrees)	MEB ~1 Mo. Pre-Sep
(20090707)	VA C&P ~7 Mo. Post-Sep
(20100327)	
Flexion (140 Normal)	130	140	
Extension (0 Normal)	0	0	

The Board directed attention to its rating recommendation based on the evidence.  The PEB rated the right knee condition 10%, coded 5099-5003 (analogous to Degenerative arthritis), citing painful motion (IAW VASRD §4.59), in the face of preserved range of motion.  The VA rated the right knee condition 10%, coded 5299-5262 (analogous to Tibia and fibula, impairment of), citing slight knee disability.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not show 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 was 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, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the right knee condition.  

Left Persistent Knee Pain (Healed Stress Fracture).  In January 2009, the CI was diagnosed with stress fracture of the medial tibial plateau of the left knee.  He was treated with medication, physical therapy (PT), and other therapeutic measures.  In spite of all treatment efforts, his knee pain persisted and an MEB was initiated.  The MEB narrative summary (NARSUM) was dated 7 July 2009.  On PE of the knees, there was no effusion, swelling, or ecchymosis.  ROM was full.  Neurological examination (sensory and motor) was normal.  The knees were nontender to palpation, and all tests for ligamentous laxity were negative.  The examiner wrote: “The service member does not have any objective physical findings at this time.  His pain is largely subjective in nature.”

At the VA C&P examination, on PE, posture and gait were normal.  PE of the knees revealed pain with motion.  The examiner wrote: “mild dysfunction due to pain.”  The ROM evaluations in evidence which the Board weighed in arriving at its recommendation, are summarized in the chart below.

Left Knee ROM
(Degrees)	MEB ~1 Mo. Pre-Sep
(20090707)	VA C&P ~7 Mo. Post-Sep
(20100327)	
Flexion (140 Normal)	130	140	
Extension (0 Normal)	0	0	

The Board directed attention to its rating recommendation based on the evidence.  The PEB rated the left knee condition 10%, coded 5099-5003 (analogous to Degenerative arthritis), citing painful motion (IAW VASRD §4.59), in the face of preserved range of motion.  The VA rated the left knee condition 10%, coded 5299-5262 (analogous to Tibia and fibula, impairment of), citing slight knee disability.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not show 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 was 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, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the left knee condition.  

BOARD FINDINGS:  In the matter of the right persistent knee pain (healed stress fracture), the Board unanimously recommends no change in the PEB adjudication, IAW VASRD §4.59, §4.40 and §4.45.  In the matter of the left persistent knee pain (healed stress fracture), the Board unanimously recommends no change in the PEB adjudication, IAW VASRD §4.59, §4.40 and §4.45.  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, dated 20140218, 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 XXXXXXXXXXXXXXXXXXXXX AR20160013466 (PD201401213)

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