RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01538
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E5, Machinist, medically separated for “right knee pain,” with a disability rating of 10%.

CI CONTENTION:  The CI contends right knee, left knee and diabetes.  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 - 20080219	VARD - 20080815	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis, Degenerative, Right Knee	5003	10%	Degenerative Joint Disease, Right Knee	5010-5260	10%	20080425	
Mild Left Knee Pain	Not Unfitting	Degenerative Joint Disease, Left Knee	5101-5260	10%		
Prediabetes		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Arthritis, Degenerative, Right Knee. According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in August 2006 after the CI caught his foot in a hole while stepping off a sidewalk and twisted his right knee.  Initial evaluations considered a tear of the medial meniscus; however, an MRI [magnetic resonance imaging] reported in November 2006 demonstrated bone bruises of the medial femoral condyle and medial tibia with significant edema a questionable fracture line in the proximal medial tibia with early degenerative joint disease and no evidence of meniscal or ligamentous findings.  An orthopedic evaluation on 14 December 2006 noted extension was full and flexion was 100 degrees (140 normal) with discomfort.  On flexion/extension of the knee, the knee failed twice, subluxating laterally slightly and there was tenderness on the posterior horn and the midsection of the medial meniscus.   The anterior and posterior cruciate ligaments seemed intact.  The diagnosis of a medial meniscal tear was made and arthroscopy and a partial or subtotal medial meniscectomy was recommended.  The CI underwent physical therapy instead of surgery.  X-rays in March 2007 demonstrated moderate to severe degenerative changes, a possible osteochondral lesion on the medial femoral condyle, and cortical thickening versus periosteal elevation along the proximal tibial diaphysis.  An X-ray series on 14 March 2007 demonstrated mild subluxation of the patella in the lateral direction along with multiple osteophytes and spurs throughout.  An MRI on 16 March 2007 demonstrated severe degenerative change of the medial compartment with severe thinning or absence of the cartilage of the medial femoral condyle and tibial plateau, and chondromalacia patella (softening or degeneration of the cartilage of the kneecap); intra-articular loose bodies could not be excluded.  X-rays of the right knee in October 2007 demonstrated tricompartmental osteoarthritis. 

Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “right knee pain” for PEB adjudication.  The MEB NARSUM dated 22 January 2008, 2 months prior to separation, noted that the CI reported knee pain present 60% of the time, which was aggravated by cold weather or exertion, and got stiff if he sat for long periods of time.  Physical examination noted no redness, warmth, or swelling, tenderness over the anterior portion of the lateral joint line, and subpatellar crepitus.

At the VA Compensation and Pension (C&P) examination in April 2008, performed 1 month after separation, the CI reported pain, locking, stiffness, swelling and occasional instability that got better with rest.  Physical examination showed normal gait, tenderness to palpation, and mild crepitus, with negative McMurray’s testing (to determine a meniscal tear).  The ligamentous examination was intact although there was 12 degrees of pseudolaxity on the right knee.

The range-of-motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Knee ROM
(Degrees)	PT ~2 Mo. Pre-Sep
	MEB ~2 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (140 Normal)	120	FROM	120	
Extension (0 Normal)	-5		0	
Comment	A 1A Lachman’s; pain on motion; antalgic gait	Tenderness anterior lateral joint line; subpatellar crepitus; no limp 	Wore brace right knee; gait normal; crepitus; McMurray negative; pseudolaxity	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5003 code (arthritis, degenerative), citing slight loss of motion for a major joint.  The VA also assigned a 10% rating using an analogous 5010-5260 code (arthritis due to trauma, substantiated by X-ray findings and leg, limitation of flexion of) based on the VA C&P examination 1 month after separation, citing painful or limited motion of a major joint with radiological evidence of degenerative changes. 

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 demonstrate the presence of ligamentous instability or laxity (5257); however there was slight subluxation laterally of the knee on one examination in December 2006; an X-ray showed mild subluxation of the patella laterally; and there was pseudolaxity of the right knee at the VA C&P examination 1 month post separation.  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).  

Because of the finding of 12 degrees of pseudolaxity on the VA examination, Board members discussed whether that could qualify for a rating using code 5257, and if so, for what rating would it would warrant.  Members agreed that the pseudolaxity was not noted prior to the VA examination, although that examination was proximate to separation and the finding was objective.  However, from a standpoint of symptomatology the CI did not complain of recurrent laxity or subluxation, although he reported experiencing occasional instability at the VA C&P examination; and a mention of subluxation was in the record only in relation to patella subluxation to the left on an X-ray series in March 2007.  Therefore, members of the Board did not feel that the pseudolaxity warranted an additional or higher rating and noted that the VA did not take it into account in its rating of the CI’s knee condition either.  Therefore, there is  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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.  

Contended PEB Conditions.  

Mild Left Knee Pain. The Board’s main charge is to assess the fairness of the PEB’s determination that the mild left knee pain was not unfitting.  The left knee was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The left knee was referred to as the good knee at an orthopedic examination in December 2006.  There were no additional notes in the service treatment record relating to the left knee other than at the physical therapy evaluation to determine the ROMs for the NARSUM, which indicated the CI developed some pain in his left knee because he overloaded it compensating for the right knee.  The NARSUM author opined the pain in the CI’s left knee was not of such significance as to limit his military career.  The VA C&P examination revealed left knee flexion was 120 degrees (140 normal) and extension was 0 degrees (0 normal) without pain.  X-rays showed moderately severe changes of degenerative joint disease with medial joint space narrowing and osteophyte formation (arthritic changes).  The aforementioned was reviewed and considered by the Board.  There was no performance-based evidence from the record that the left knee significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 left knee contended condition and so no additional disability rating is recommended.  

Prediabetes.  The prediabetes was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.   The NARSUM stated the following reference the diabetes: “This Soldier was found to have a fasting blood sugar 132 on his Phase II exam.  Repeat blood sugar was within the normal range.  He is not taking any medications. He is monitoring diet and has successfully lost 15 pounds. He is intent on controlling his disease through diet and exercise.” The aforementioned was reviewed and considered by the Board.  There was no performance-based evidence from the record that the prediabetes condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 prediabetes contended condition and so no additional disability rating is 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 contended left knee and prediabetes conditions, the Board unanimously recommends no change from the PEB determination 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 20140227, 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 XXXXXXXXXXXXXXXXXXXXXXX AR20160010512 (PD201401538)

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