RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD 2014-01371
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for left knee instability.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L4 profile and referred for an Medical Evaluation Board (MEB).  Posterior lateral instability of the left knee was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded wrist pain and decreased function for PEB adjudication.  The Informal PEB adjudicated left knee instability as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  He received a higher rating from the VA for his conditions.  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 condition outside the Board’s defined scope of review (such as the additional abdomen and PTSD conditions cited in the contention) 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 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  IPEB – Dated 20031217	VA* - (~3.2 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Instability	5313	10%	Residuals of Left Knee Injury with Limitation of Motion	5262	10%	20040127	
			Residuals of Left Knee Injury with Laxity, Postoperative	5257	10%	20040127	
Wrist Pain and Decreased Function	Not Unfitting	Residuals of Left (Dominant) Wrist Fracture	5215	10%	20040127	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20040426 (most proximate to date of separation [DOS])
ANALYSIS SUMMARY:

Left Knee.  In early 2002 the CI was in a motor vehicle accident and received multi-system trauma to include a dislocated left knee.  The CI underwent two separate left knee surgeries within an 8-month period; culminating in a reconstruction of his left knee in October 2002.  Post-operatively, he did well with aggressive physical therapy whereby on 03 June 2003 (7 months after surgery) the orthopedist commented, “good result from knee reconstruction”.  Noting mild residual posterior collateral ligament (PCL) laxity, the orthopedist recommended an MEB.  At the MEB narrative summary (NARSUM) examination (6 months pre-separation) the CI’s chief complaint was left knee instability.  The physical examination revealed global instability and laxity about the left knee citing only the medial collateral ligament as being ‘taut’ (aka…normal).  His gait was altered and slight weakness of the left lower extremity was present.  A range-of-motion (ROM) of at least 90 degrees of left knee flexion was demonstrated.  There were no other ROM parameters identified.  His diagnosis was listed as posterior lateral instability of the left knee.

At the VA Compensation and Pension (C&P) examination (3 months pre-separation), the CI’s chief complaint was ‘residuals of left knee injury’.  His physical exam revealed marked crepitus and global instability about the left knee.  There was minimal decreased ROM noting 120 degrees of left knee flexion after a five degree offset due to repetition; extension was normal.  Under the heading of ‘Functional Assessment’, the examiner stated, “The [CI] can walk up to 2 miles without difficulty”.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left knee condition under the Group XIII muscle code of 5313 at 10% (moderate) impairment citing muscle weakness of the left lower extremity.  The VA utilized two separate codes of 5262 (Tibia/fibula impairment) and 5257 (Knee; other impairment) at 10% each indicating ‘slight’ impairment, respectively.  Absent any degree of ankylosis, compensable ROM, frequent locking, or mal-union/non-union of the knee joint, Board members agreed that the PEB’s 10% rating was easily supported under the VA’s chosen code of 5257 given the clear and distinct evidence of instability and laxity in the left knee at both the MEB and VA examinations.  Members additionally agreed that the PEB’s chosen muscle code did not adequately represent the present instability when compared to code 5257.  Therefore, deliberation continued as to the degree of impairment between ‘slight’ (10%) and ‘moderate’ (20%) under code 5257.  Board members agreed that the VA exam, most proximate to the separation, documented a 15% decrement in knee flexion or “120” degrees of 140 [normal] degrees) and the CI’s ability to “…walk up to 2 miles without difficulty” supports a rating no greater than ‘slight’ (10%) impairment which is equivalent to the PEB’s 10% rating.  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 Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left (dominant) wrist condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (Reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Pursuant to the same motor vehicle accident described above, the CI also fractured his left wrist (distal ulna) which required surgical fixation (placement of a single screw) on 05 February 2002 and removed a year later on 28 February 2003.  One month after surgery, the orthopedic provider documented full ROM of the left wrist and the CI was referred to occupational therapy (OT).  There were two OT encounter notes (2 weeks apart) contained in the case file that revealed very near normal wrist ROM as well as a 33% average improvement in left hand grip strength.  The NARSUM physical exam (6 months pre-separation) revealed full ROM of the left wrist.  The examiner specifically noted “good functional studies as per OT” as well as comparison grip strength being slightly less on the left upper extremity.  Pain was associated with lifting and carrying.  The VA C&P physical exam revealed full wrist ROM and comparison grip strength was measured as follows:

Right wrist = 100 and 90 (pounds)…equivalent to 45 and 41 kilograms 
Left (dominant) wrist = 85 and 90 (pounds)…equivalent to 39 and 41 kilograms

Board members agreed that the above measurements correspond to recommended normal grip values as published in current medical literature.  The commander’s statement included “…due to [the CI’s] unstable left knee and left wrist weakness, he was unable to perform almost any military duties.”  Board members extensively deliberated and agreed that the commander’s statement and the CI’s profiled restrictions of no push-ups, no climbing in/out of military tactical vehicles, 10 pound lifting restriction, and no weapon use were indicative of performance based evidence that significantly interfered with satisfactory duty performance.  Based on the preponderance of evidence the Board recommends the left wrist as an additional unfitting condition for disability rating.

Absent compensable left wrist ROM parameters, the Board agreed that pain described with ‘lifting and carrying’ indeed reflects motion in the multi-jointed wrist and supports VASRD §4.59 (Painful motion) and §4.40 (Functional loss).  After due deliberation, considering the preponderance of evidence, the Board recommends a disability rating of 10% with codes 5010-5003 (Arthritis, due to trauma and arthritis degenerative).

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 left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left wrist condition, the Board unanimously agreed that it was unfitting and unanimously recommends a disability rating of 10%, coded 5010-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Left knee Instability	5257	10%	
Left Wrist Pain	5010-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201401371, 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 XXXXXXXXXXXXXXXXXXXX, AR20160003994 (PD201401371)

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 20% 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