RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01276
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E4, Food Service Operations, medically separated for “left knee pain secondary to pes bursitis,” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention in the application.  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 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 - 20060418	VARD - 20070811	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain Secondary to Pes Bursitis	5019	0%	Degenerative Changes Left Medial Compartment, Left Knee, with Bursitis	5010	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Knee Pain Secondary to Pes Bursitis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee pain secondary to pes bursitis began in October 2005 after an injury during a training exercise.  An MRI study in November 2005 showed a small joint effusion (swelling due to fluid buildup), a medial collateral ligament (MCL) sprain, with degenerative changes in the lateral joint compartment and patellofemoral joint.  A “minimal” tear versus degeneration was noted involving the lateral meniscus, but all ligaments were intact.  At a family practice clinic examination on 23 November 2005 (6 months pre-separation), the CI reported improved swelling with continued 5/10 pain, inability to straighten the knee and episodes of sudden locking and buckling.  Physical examination noted tenderness on ambulation, patellar crepitus, with no tenderness on palpation.  Testing indicated laxity of the anterior collateral ligament (positive Lachman test) with no evidence of lateral and medial instability.  Testing for meniscal injury (McMurray and Apley tests) was positive.  Range of motion (ROM) was limited by pain with no specific measurements documented.  At an orthopedic clinic examination on 29 November 2005 (6 months pre-separation), the CI reported being employed as a factory worker in his civilian occupation and as a cook for his military duty.  He reported anterior knee pain with no instability and denied trauma or prior injury.  Physical examination demonstrated pain with patellar compression, “full” ROM, no effusion, and no evidence of ligamentous laxity.  At a physical therapy examination on 12 January 2006 (4 months pre-separation), the CI reported 4/10 pain, increasing to 8/10 at night.  Pain was worse at night and aggravated by excessive walking, sitting, or stair climbing.  Physical examination showed an antalgic gait with “significant” patellar crepitus, and “abnormal excessive movement.”  There was tenderness at the joint line, around the patella, and with patellar compression.  The CI was unable to partially squat due to pain; however, the ROM was “full,” and there was no evidence of laxity, instability or meniscal damage.  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 due to bursitis” for PEB adjudication.  

At the MEB NARSUM examination on 9 February 2006 (3 months pre-separation), the CI reported knee pain aggravated by prolonged standing, marching, maneuvering stairs, and inability to run due to pain.  Physical examination showed a normal gait with full extension to 0 degrees (normal), and flexion to 130 degrees (normal 140), both with pain.  There was tenderness on patellar compression and at the medial knee (at the pes bursa).  There was no evidence of meniscal damage or ligamentous instability.  

At a visit with orthopedics in December 2006 (7 months post-separation), the CI reported continue pain, popping, grinding, difficulty bending, standing, climbing stairs, lifting and walking.  The examiner documented an antalgic gait, pain with patellar compression, effusion, and tenderness about the knee and medial joint line.  There was pain with deep flexion and evidence of meniscal injury (positive McMurray’s and Apley testing).  Further radiographic imaging (MRI) that day documented a tear in the anterior horn of the lateral meniscus and lateral patellar tilt.  The CI failed to show for his scheduled VA Compensation and Pension (C&P) examination in May 2007 (12 months post-separation).  Arthroscopic repair (meniscectomy and chondroplasty) was performed in December 2007 (27 months post-separation).  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5019 code (arthritis, degenerative, bursitis), citing normal ranges of motion.  The VA assigned a 10% rating using the 5010 code (arthritis, degenerative, due to trauma) based on record review, citing painful or limited motion of a major joint.  

In considering support for a higher rating, the Board noted the CI complained of “buckling and locking” during the 23 November 2005 family practice examination (cited above) but nowhere else during subsequent exams were similar complaints in evidence.  The same family practice examination reported ligamentous laxity and meniscal injury.  All other examinations, including the orthopedic examination (November 2005, one week later), and the physical therapy examination (January 2006) noted the presence of completely stable ligaments with no evidence of meniscal injury.  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.  

Board members debated the significance of the family practice examination while other exams noted negative testing.  The Board concluded that there was insufficient evidence to meet the standard of reasonable doubt to show ligament instability or meniscal injury in order to support dual coding under 5257, 5258, or 5259.   There was no limitation of flexion or extension that supported a higher rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee pain secondary to pes bursitis condition, coded 5019 (bursitis).   

BOARD FINDINGS:  In the matter of the left knee pain secondary to pes bursitis condition, the Board unanimously recommends a disability rating of 10%, coded 5019 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain Secondary to Pes Bursitis 	5019	10%	

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

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 AR2016001 0065 (PD201401276)

1. 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,
accept the Board's recommendation to modify the individual's disability rating to 10%
without re-characterization of the individual's separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be
corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided
to the individual concerned, counsel (if any), any Members of Congress who have
shown interest, and to the Army Review Boards Agency with a copy of this
memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF:
( ) DoD PDBR
( ) DVA