RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01400
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Unit Supply Specialist, medically separated for “bilateral knee pain,” with a disability rating of 20%.

CI CONTENTION:  “More severe problems, including secondary issue.”  The applicant’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 -  20090402	VARD -  20100320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	Right Knee Strain, Post-Operative	5099-5024	10%	20091221	
Left Knee Pain	5099-5003	10%	Patellofemoral Syndrome, Left Knee Associated with Right Knee Strain, Post-Operative	5099-5024	10%	20091221	
Degenerative Arthritis of the Spine L4-L5 w/Left Leg Radiculitis	5242	--%	Residuals of a Back Injury	5299-5242	NSC	20091221	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right and Left Knee Pain.  The service treatment record (STR) and narrative summary (NARSUM) documented the onset of non-traumatic right knee pain during physical training activities at advanced individual training (AIT) in June 2004.  At a primary care visit on 8 July 2004, the examiner noted CI complaints of bilateral knee pain for 2 weeks.  The CI was diagnosed with “severe right prepatellar tendonitis” and an arthroscopy was performed on the right knee in October 2004 (partial medial meniscectomy and medial plica excision).  At a follow-up visit in April 2005, the CI reported occasional giving out and the orthopedic examiner documented no effusion, no instability, and no laxity or meniscal pathology.  At a physical therapy visit on 26 April 2005, the examiner documented an “uncomfortable” right knee examination with an antalgic gait, a range-of-motion (ROM) of 0-130 degrees (normal 0-140), and 4/5 strength.  

Despite treatment, the right and 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 “right knee pain status post meniscectomy with residual pain” and “patellofemoral syndrome, left knee” for PEB adjudication.

At the MEB NARSUM examination performed on 3 December 2008, the CI reported continued 5/10 pain since the 2004 surgery.  His knee pain was worsened by standing more than 3 hours, walking more than 1/2 mile, and sitting for 2 hours.  He was unable to kneel or squat repetitively without significant increase in pain.  He reported left knee pain beginning in 2005 that caused his knee to “give out and buckle.”  The examiner documented right knee tenderness along the lateral joint line and left knee tenderness of the medial joint line.  There was no swelling and no evidence of instability, laxity, or meniscal pathology in both knees.  There was bilateral flexion to 130 degrees with bilateral evidence of painful motion and patellofemoral crepitus.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated December 2008, 5 months prior to separation, the CI reported use of bilateral knee braces and a cane; that both knees swelled at night; and that there was locking and giving way of the left knee.  Physical examination documented the inability to squat without documenting ROM; and diagnosed bilateral meniscal and anterior cruciate ligament tears.  There was no radiographic documentation in evidence.  

At the VA Compensation and Pension (C&P) examination performed on 21 December 2009, 7 months post-separation, the CI reported constant 7/10 knee pain with nightly flare-ups after prolonged standing and walking.  He reported intermittent use of a cane, and denied a major impact on his occupation and activities of daily living.  He could stand for 30-40 minutes, and walk 3/4 of a mile.  The examiner documented a “mild” limp, with squatting and kneeling that was “very painful and difficult.”  Right knee ROM was 0-100 degrees with pain and left knee ROM was 0-105 degrees without pain.  Laxity was noted on the right with varus stress, with no anterior or posterior laxity bilaterally.  Repetition did not alter the ROM.  Radiographic evaluation at that time documented no bony or joint abnormalities.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the bilateral knee pain individually at 10% for the right and 10% for the left, citing tenderness, painful motion, and crepitus, analogously coded 5099-5003 (degenerative arthritis) for a combined rating of 20%.  The VA rated the “right knee strain, post-operative” at 10%, and the “left knee patellofemoral syndrome…” at 10%, with both analogously coded 5099-5024 (degenerative arthritis, tenosynovitis).  

Right Knee Pain.  The Board considered the evidence for a rating higher than 10%.  There was no limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate recurrent subluxation, lateral instability, or frequent locking with effusions (or any indication of dislocated meniscus or loose body) for a route to a rating higher than 10% under any other diagnostic codes (5257 or 5258), and no grounds for additional rating based on instability.  There was evidence of tenderness, painful motion, crepitus, with limitation of motion that persisted after surgery and after separation supporting the 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5099-5003 or 5099-5024 as adjudicated by the PEB and the VA.  The Board also noted a 10% rating was supported under VASRD diagnostic code 5259 (cartilage, semilunar, removal of, symptomatic) but provided no benefit to the CI.  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 Knee Pain.  The Board considered the evidence for a rating higher than 10%.  As with the right knee, there was no limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261); and no recurrent subluxation, lateral instability, or frequent locking with effusions for a route to a higher rating under any other diagnostic knee codes or for an additional rating based on instability.  There was evidence of tenderness, painful motion, crepitus, with limitation of motion at the time of separation supporting the 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5099-5003 or 5099-5024 as adjudicated by the PEB and the VA.  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.  

L4-L5 Degenerative Arthritis with Left Leg Radiculopathy.  The PEB determined that the low back condition existed prior to service based on the CI’s own report (during the MEB NARSUM exam) that the condition began “while performing his civilian job requirements” in January 2007 and further stated that the condition was “not rated as it [was] related to civilian injury without evidence that it [was] worsened by military service.”  The Board considered whether or not there was evidence of service aggravation.  There was only one report of low back pain in July 2004 that resulted from “twisting back [when] awakening.”  Civilian entries through 2005 addressed only the knee condition.  There were no further STR entries in evidence until the date of the MEB NARSUM, as noted previously.  After due deliberation, considering all of the evidence, the Board concluded that the low back and radiculopathy conditions were not permanently aggravated by service beyond the natural progression of the condition and therefore recommends no change in the PEB’s adjudication.  

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 knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the L4-L5 degenerative arthritis with left leg radiculopathy and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication that the condition existed prior to service and was not permanently aggravated by service beyond the natural progression.  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 20140314, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160006047, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR)
reviewed your application and found your separation disability rating and your
separation from the Army for disability with severance pay to be accurate. I have
reviewed the Board's recommendation and record of proceedings (copy enclosed), and
I accept its recommendation. I regret to inform you that your application to the DoD
PDBR is denied.

This decision is final. Recourse within the Department of Defense or the
Department of the Army is exhausted; however, you have the option to seek relief by
filing suit in a court of appropriate jurisdiction.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure