RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01583
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20071231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, Aeromedical Evacuation Officer, medically separated for “chronic left knee pain,” with a disability rating of 10%.  

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  Her 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 - 20071030	VARD - 20080813	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Left Knee Strain, Status Post ACL Repair	5260-5010	10%	20080421	
Occasional Episodes of Bronchitis and Functional Heart Murmur	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Knee Condition.  According to Service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a left knee injury (West Point competing in intercollegiate athletics) approximately 7 years prior to referral for MEB.  An orthopedic sick call encounter reported a left knee MRI showed an anterior cruciate ligament (ACL) tear, bone bruises, and intact menisci.  The CI underwent an ACL reconstruction.  The CI experienced episodic worsening of left knee symptoms as a UH-60A Blackhawk MEDEVAC pilot in support US Marine Corps and Coalition Forces in Operation Iraqi Freedom 05-07.  In spite of escalating symptoms, the CI continued to operate from an isolated Forward Operating Base in the western desert of Iraq conducting combat MEDEVAC missions.  Because of the high operational tempo, and the CI flying during almost every duty cycle, she experienced progressive left knee instability, effusion (fluid collection), stiffness, and pain.  The left knee examination by orthopedic surgery revealed a moderate effusion, tight hamstrings, and quadriceps atrophy.  The Lachman (assesses ACL) test revealed a lax endpoint and pivot shift (assesses ACL) test was graded as slight (1+).  There was a “solid” posterior cruciate ligament (PCL) and the valgus/varus stress (assesses medial collateral ligament [MCL]/lateral collateral ligament [LCL]) was “stable.”  Because the instability component had worsened, the orthopedic surgeon and flight surgeon grounded the CI from flying status.  A left knee X-ray showed findings consistent with an ACL reconstruction and no evidence of an acute osseous abnormality.  A left knee MRI showed an intact ACL graft and no evidence of internal derangement.  An orthopedic surgery left knee examination revealed well healed incisions and the PCL was intact.  The Lachman test was grade 2 soft A (5-10mm translation/soft endpoint) and the McMurray (assesses menisci) was positive with lateral popping/pain.  The valgus/varus stress, patellar grind (assesses abnormal patellar movement and painful crepitation), and patellar apprehension (apprehension or pain on quadriceps contraction with patella displaced) tests were negative.  Left knee range-of-motion (ROM) was flexion of 135 (140 normal) and extension of 0 (0 normal) degrees.  The surgeon opined that the CI had failed conservative treatment and scheduled arthroscopy.  The left knee weight bearing X-rays showed postoperative changes status post ACL reconstruction with no evidence for acute disease.  Orthopedic surgery performed left knee arthroscopy with debridement.  Because of continued left knee pain, orthopedic surgery performed a steroid injection into a bursa (pes anserine) and the area of the tibial screw.  Because of continued symptoms, orthopedic surgery performed injection of the left knee joint with Synvisc (synthetic synovial [joint] fluid).  Physical therapy (PT) measured repetitive active ROM for the MEB with a goniometer.  The CI complained of left knee 4/10 aching pressure pain.  The physical examination documented an antalgic (assuming a gait or posture to lessen pain) gait with no knee weakness observed.  The left knee examination revealed anterior tenderness distal to the patella.  Left knee active ROM was flexion of 130/130/130 (140 normal) and extension of 0/0/0 (0 normal) degrees.  The therapist opined that there was mechanical limitation secondary to soft tissue.  

The NARSUM, 4 months before separation, recounted the history and interventions.  The CI reported insidious onset of left knee pain while deployed.  She failed to improve with both conservative (activity modification, PT, steroid injection, Synvisc injection, and medications) management and operative procedures.  The CI complained of chronic 3-4/10 left knee pain with exacerbations to 6/10.  Pain was exacerbated by prolonged sitting (90 minutes), standing (5 minutes), walking (one mile), and weight bearing.  The discomfort was characterized as global aching, anteromedial pressure, and patellar sharp pain.  She complained of knee locking with complete extension and reported that pain interfered with sleep every 3 to 4 days.  Active medications were the nonsteroidal anti-inflammatory drug (NSAID) Mobic and an opioid receptor agonist (Ultram).  The examiner recounted the findings of the left knee X-rays and MRI.  The physical examination documented no limp was detected.  The left thigh and left calf were smaller than the right side.  The left knee examination revealed no redness, swelling, or warmth, but a surgical screw head was visible through the skin.  There was an area of atrophy distal and medial to the knee, secondary to the cortisone injections, that was hypersensitive to touch.  There was slight tenderness of the medial joint line and an area of decreased sensation of the anterolateral knee.  The ligaments were stable and there was minimal patellar crepitus (grating sensation or sound).  The left knee ROM was full.  The impression listed left knee pain.  

The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of chronic 4/10 left knee pain with exacerbations to 7/10.  She reported associated weakness, stiffness, swelling, giving way, locking, fatigability, and lack of endurance but denied heat, redness, or dislocation.  Pain was exacerbated by activity, bending, lifting, load bearing, walking, and stairs and relieved by rest and medications (Ibuprofen and Tylenol).  The discomfort was characterized as aching and sharp.  The physical examination documented a normal gait without an assistive device.  The left knee skin examination revealed healed surgical scars with an elevated and tender anterior inferior scar with circumscribed disfigurement, tissue loss, and hyperpigmentation.  The left knee examination revealed tenderness, locking pain, guarding of movement, and skin/subcutaneous tissue atrophy.  There was no edema (excess tissue fluid swelling), effusion, redness, heat, or subluxation (incomplete or partial dislocation), genu recurvatum, or crepitus.  The ACL, PCL, MCL, and LCL stability tests, and medial and lateral meniscus tests, were within normal limits.  Left knee ROM was flexion of 135 (140 normal) and extension of 0 (0 normal) degrees.  After repetitive use, the left knee was additionally limited by pain, with pain having the major functional impact.  After repetitive use, the left knee was not additionally limited by fatigue, weakness, lack of endurance, or incoordination.  Strength, sensation, pulses, and deep tendon reflexes (DTRs) were normal.  The left knee X-ray showed postoperative changes status post ACL repair but was otherwise negative.  The diagnosis listed left knee strain status post ACL repair.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% (10% minus undetermined EPTS factor equals 10% net rating) rating under an analogous 5003 code (degenerative arthritis).  The PEB cited ACL tear, status post ACL repair with no sequela, chronic left knee pain, decreased function, diagnostic arthroscopy showed no surgical corrective conditions, ROM of 0-130 degrees, some loss of joint motion, no evidence of joint instability, condition existed prior to service, and was permanently service aggravated by repetitive strain.  The VA assigned a 10% rating under the 5260-5010 codes (leg limitation of flexion-traumatic arthritis) based on the VA C&P examination 4 months after separation.  The VA cited left knee strain, status post ACL repair without sequela, EPTS, permanently worsened by service, no EPTS deduction because preservice percentage was zero, knee reinjury, aching pain, sharp pain, pain exacerbated by activity, pain relieved by rest and medications, weakness, stiffness, swelling, giving way, locking, fatigability, lack of endurance,  tenderness, locking pain, guarding of movement, skin/subcutaneous tissue atrophy, no edema, no effusion, no redness, no heat, no subluxation, no genu recurvatum, no crepitus, stability (ACL, PCL, MCL, and LCL) tests within normal limits, meniscus tests within normal limits, ROM, additionally limited by pain after repetitive ROM, not additionally limited by fatigue, weakness, lack of endurance, or incoordination after repetitive ROM, and X-ray findings.  The proximate (PT, NARSUM, and C&P) examinaitons did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), 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.  Board members agreed that there was sufficient evidence of pain with use, as well objective examination findings, to support a 10% rating considering VASRD §4.40 (functional loss) and §4.59 (painful motion).  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.

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140114, 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-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

28 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160006759 (PD201401583)

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