RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01353
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20091118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Infantryman, medically separated for “right knee pain” and “left wrist pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “I believe I was unfairly rated based upon my conditions, and was not rated for other conditions that should have been taken into consideration at the time of discharge, which would have enabled me to be medically retired by the Army if taken into consideration.  To include PTSD, back and neck issues.” [Sic]  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:  

SERVIC PEB - 20090813	VARD - 20091210  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	Right Knee	5260-5024	10%	20090915	
Left Wrist Pain	5099-5003	10%	Left Wrist	5215-5024	10%	20090915	
Recurrent Bilateral Shoulder Pain	Not Unfitting	Right Shoulder	5201-5024	10%	20090915	
		Left Shoulder	5201-5024	10%	20090915	
Recurrent Achilles Tendinitis		Right Ankle Talofibular Strain	5271-5024	10%	20090915	
Recurrent Lumbar Strain		Lumbar Spine Strain	5237	10%	20090915	
Anxiety Disorder		Anxiety Disorder	9413	NSC	20091014	
		Post-Traumatic Stress Disorder	9411	10%	20091014	
High Blood Pressure		Hypertension	7101	0%	20090915	
Lipoma		No VA Placement	
Asymptomatic Pes Planus		Bilateral Pes Planus	5276	0%	20090915	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Right Knee.  According to Service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right knee symptoms began approximately 7 years prior to referral for MEB.  Right knee diagnostic imaging (MRI [magnetic resonance imaging]) revealed a torn anterior cruciate ligament (ACL) and possible partial posterior cruciate ligament (PCL) tear.  The CI underwent right knee arthroscopy which revealed medial meniscus, lateral meniscus, and ACL tears.  The orthopedic surgeon performed a medial meniscus repair and hamstring reconstruction of the ACL.  The 3-month postoperative orthopedic surgery exam documented well healed wounds and full range of motion (ROM) with no effusion (fluid collection) or laxity.  Seven months post-operatively, diagnostic imaging (MRI) documented the ACL graft was in “perfect anatomic alignment” and the impression listed “normal postoperative right knee MRI.”  The 19 July 2009 NARSUM, 4 months before separation, recounted the history and interventions.  Following postoperative physical therapy (PT) the CI had a reasonable result.  He complained of right knee pain with prolonged standing, jumping, and running.  The active medication was an opioid receptor agonist (Tramadol) occasionally as needed.  The examiner cited the general physical exam which documented that the lower extremities were normal, except for right knee surgical scars, and listed the diagnosis of right knee pain.  A focused right knee exam documented a stable knee with a normal 1+ (< 5mm translation) Lachman (assesses ACL).  The goniometer measured ROM values were flexion of 130 (140 normal) and extension of 0 (0) degrees.  The diagnosis listed right knee pain, status-post ACL repair, with no significant instability.  

The 15 September 2009 Compensation and Pension (C&P) exam recounted the history and interventions.  The CI reported the right knee pain and stability were “very much better” after the surgery.  He complained of daily minimal to mild pain and denied locking or giving way.  Pain was exacerbated by activity and relieved by rest.  The physical exam documented a normal gait with no assistive devices.  The right knee exam revealed no visible arthroscopy scar or swelling.  The supra- and infrapatellar tendons were normal and the medial collateral ligament (MCL) was stable.  The Lachman, drawer (assesses ACL and PCL), and McMurray (assesses menisci) tests were negative.  Pain limited active ROM values were flexion of 120 (140) and extension of 0 (0) degrees.  Repetitive (X3) ROM was limited by pain and impaired endurance.  The examiner recounted the finding of the postoperative MRI.  The diagnosis listed right knee status post ACL surgery with hamstring graft, healed with residual, recurrent, episodic pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis) citing right knee twisting injury, ACL tear requiring surgical repair, right knee pain, stable knee, ROM, and pain with ROM.  The VA assigned a 10% rating under the 5260-5024 codes (limitation of flexion of leg-tenosynovitis ) based on the VA C&P exam 2 months before separation, citing ACL and meniscal tears, status post ACL reconstruction and medial meniscus repair, right knee pain, brace as needed, normal gait, no visible scar, no edema (swelling), no effusion, no redness, no heat, no genu recurvatum (bowing of the lower leg), no tenderness, no weakness, no subluxation, no crepitus (cracking), no locking pain, no ankylosis (freezing in place), no guarding of movement, stable ligaments, stable menisci, pain on McMurray, ROM, painful ROM, pain and lack of endurance with repetitive use, and no fatigue, weakness, or incoordination on repetitive use.  The proximate (NARSUM and C&P) exams did not demonstrate a limitation of motion to support a minimum rating under limitation of flexion (5260) or extension (5261).  While the CI underwent a medial meniscus repair, there was no dislocated meniscus (5258) or symptomatic removed meniscus (5259) for consideration under the respective codes.  There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  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 Wrist.  According to STR and NARSUM, the left wrist condition began approximately 16 months prior to referral for MEB.  Left wrist diagnostic imaging (X-ray) showed posterior subluxation (incomplete dislocation) of the ulna with respect to the radius.  Subsequent diagnostic imaging (MRI) showed mild ulna subluxation, distal radioulnar joint distention, and detachment of the triangular fibrocartilage complex ([TFCC] major ligamentous stabilizer that suspends carpals against ulna and radius) from the ulna.  The CI underwent a left wrist injection with local anesthetic (Lidocaine) and corticosteroid (Kenalog).  Failing conservative management, the CI underwent and arthroscopic repair of his TFCC tear.  At an occupational therapy (OT) encounter, the CI complained of intermittent, 2/10, dull throbbing, and pulling left wrist pain.  The left wrist exam revealed two small, flat, pink, and pliable surgical scars and no tenderness.  There was mild muscle atrophy, mild edema of the ulnar wrist, and ulnar head prominence.  Active ROM was dorsiflexion of 80 (70 normal) and palmar flexion of 70 (80) degrees.  Seven months postoperatively, diagnostic imaging (MRI) documented status post TFCC repair and “no present abnormality is evident.”  A hand clinic follow-up documented there was no subluxation of the distal radioulnar joint in both pronation and supination.  The surgeon did not recommend an intervention at that point and discharged the CI from his care.  The NARSUM recounted the history and interventions.  The CI initially had good results with postoperative OT.  This was followed by a recurrence of “painful popping,” persistent tenderness, and pain with pronation and ulnar deviation.  The active medication was Tramadol as needed and the examiner cited the general physical exam.  A focused left wrist exam documented a very prominent distal ulna (ulnar styloid process).  The goniometer measured ROM values were dorsiflexion of 60 (70), palmar flexion of 40 (80), radial deviation of 18 (20), and ulnar deviation of 30 (45) degrees.  The diagnosis listed left wrist pain status post TFCC repair.  

The C&P exam recounted the history and interventions.  The right hand dominant CI complained of daily minimal to mild left wrist pain and a weak grasp.  He denied numbness or tingling in the digits.  Pain was exacerbated by activity (pushing and pulling) and relieved by rest.  The left wrist exam revealed 2 tiny surgical scars and normal forearm musculature with no keloid (abnormal/excessive scar tissue) or hypertrophy (enlargement from constituent cell size increase).  There was no restricted underlying joint movements on muscle movements.  Subluxation of the distal ulnar joint did not cause localized pain.  Active ROM values were dorsiflexion of 60 (70), palmar flexion of 75 (80), radial deviation of 20 (20), and ulnar deviation of 40 (45) degrees.  Repetitive (X3) ROM was limited by pain and impaired endurance.  The examiner recounted the finding of the postoperative MRI.  The diagnosis listed left wrist TFCC repair with the residual, recurrent, episodic pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis) citing left wrist strain, MRI findings, TFCC repair, left wrist pain and tenderness,  prominent ulnar styloid process, ROM, and pain with ROM.  The VA assigned a 10% rating under the 5215-5024 codes (limitation of motion of wrist-tenosynovitis) based on the VA C&P exam citing wrist sprain, wrist joint derangement, status post TFCC repair, left wrist pain, weakness, brace as needed, two small scars with no disfigurement or functional limitation, no edema, no effusion, no redness, no heat, no tenderness, no guarding of movement, subluxation at the distal ulnar joint, ROM, painful ROM, pain, lack of endurance,  and slightly reduced grip strength  with repetitive use, and no fatigue, weakness, or incoordination on repetitive use.  While the CI underwent a TFCC repair, there was no ulna or radius flail false joint (5210), significant loss of bone substance, marked deformity, nonunion, or malunion (5211 and 5212), or impairment of supination or pronation (5213) for consideration under the respective codes.  Physical exams, and diagnostic imaging, did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation (5214) for consideration under the respective code.  The limitation of motion (5215) in the proximate (NARSUM and C&P) exams did not attain a minimum rating.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  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 wrist condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral shoulder pain, Achilles tendinitis, lumbar strain, anxiety disorder, high blood pressure, lipoma, and pes planus 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.  The contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  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.  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:  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left wrist condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral shoulder pain, Achilles tendinitis, lumbar strain, anxiety disorder, high blood pressure, lipoma, and pes planus conditions, the Board unanimously recommends no change from the PEB determinations 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, dated 20140311, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008563 (PD201401353)

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