RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-01692
BRANCH OF SERVICE:  Army	BOARD DATE:  20141023
SEPARATION DATE:  20021004

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Duty CPT/O-3 (74B/Chemical Defense Warfare Officer) medically separated for a left knee condition.  The left knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  His profile allowed for an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “traumatic osteoarthritis, osteochondritis dissecans (OCD) lesion over the lateral femoral condyle and tibial plateau, status post (s/p) anterior cruciate ligament (ACL) reconstruction and s/p microfracture of the left femoral condyle”  were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “traumatic osteoarthritis left knee, with OCD lesions, lateral femoral condyle and tibial plateau, s/p ACL reconstruction and microfracture of left femoral condyle” as a single unfitting condition, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all known conditions.”

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting left knee condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20020619	VA - (7 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Traumatic Osteoarthritis Left Knee, w/OCD Lesions, s/p ACL Reconstruction 	5003	10%	Arthritis, Left Knee	5260	10%	20020311	
Other x 0 (Not in Scope)	Other x 0		
Rating:  10%	Rating:  10%	
Derived from VA Rating Decision (VARD) dated 20020513 (most proximate to date of separation [DOS]).
VARD 20050107 granted separate 10% rating for instability of the left knee (5257) effective the day after separation.

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

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

Left Knee ROM
(Degrees)	Ortho 
~ 9 Mo. Pre-Sep
(20020123)	Ortho 
~ 8 Mo. Pre-Sep
(20020206)  
	VA C&P 
~ 7 Mo. Pre-Sep
(20020311) 	MEB NARSUM
~ 5 Mo. Pre-Sep
(20020509) 
	
Flexion (140 Normal)	130	140	120	135	
Extension (0 Normal)	0	0	0	0	
Comment	1A Lachman with firm endpoint 	1+ Lachman with good endpoint	Pain at end range of motion	1+ Lachman with definite end point	
§4.71a Rating	10%	10%	10%	10%	

The CI underwent arthroscopic surgery of the left knee on 14 May 2001 for repair of a torn ACL, partial removal of the lateral and medial menisci (for tears) and microfracture of the lateral femoral condyle (thigh bone portion of the knee joint) for loss of joint surface cartilage (degenerative process due to osteochondritis dessicans).  An orthopedic examination performed on 23 January 2002, noted a complaint of instability and pain with use.  On examination, the Lachman test for ACL instability was graded as 1A indicating mild movement but with a firm endpoint indicating an intact ACL graft.  The knee was stable to lateral stress (valgus and varus) and ROM was mildly reduced in flexion (noted in chart).  Magnetic resonance imaging (MRI) of the left knee on 30 January 2002 demonstrated the ACL graft was intact (as well as the other ligaments) and degenerative changes.  At the time of a follow-up orthopedic examination on 6 February 2002, there was pain with walking and running.  On examination, the ROM was normal.  The Lachman was 1+ with a good endpoint (consistent with intact ACL graft) and a stable anterior and posterior drawer maneuvers (also indicating absence of instability).  

The VA Compensation and Pension (C&P) examination on 11 March 2002, recorded the CI’s history of pain, weakness and requiring a brace to stand and walk.  The ROM observed at the C&P examination is recorded on the chart above and described the functional limitation caused by the knee condition as slight.  No examination tests for ligamentous instability were recorded.  X-rays demonstrated degenerative changes.  The MEB orthopedic narrative summary performed on 9 May 2002, reported persistent left knee pain with use.  The CI was able to function in Garrison but was not able to function in the field, run, jump or ruck march due to pain.  On examination, there was slight limitation of flexion (recorded in the chart), with crepitus (grinding sensation) noted by the examiner.  The lateral femoral condyle of the left knee was tender.  The Lachman test showed mild laxity with a definite end point (indicating an intact ACL graft).  The anterior drawer was negative for ACL instability and tests of all other ligaments were normal.  A subsequent VA C&P examination in November 2003 (a year after separation) recorded absence of knee ligament instability on examination, with a negative anterior drawer and negative Lachman test.  At the July 2004 C&P examination (21 months after separation), the CI complained of occasional feeling of knee instability after sitting or standing for 20 minutes but the examination reported absence of instability.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the left knee traumatic arthritis (with osteochondritis dessicans lesions and s/p ACL reconstruction and femoral condyle microfracture) at 10%, using code 5003 (degenerative arthritis).  The VA rated left knee arthritis 10% (analogously to code 5260, limitation of flexion) citing functional impairment with use.  The VARD performed on 7 January 2005 granted an additional 10% rating for instability of the left knee (5257) based on the July 2004 VA C&P examination recording subjective symptoms of instability after standing or sitting.  The ROM examinations proximate to separation did not show limitation of motion of the left knee that attained a minimum rating under VA diagnostic codes for limitation of flexion or limitation of extension (5260, 5261).  There was evidence of functional loss (§4.40) to support the 10% rating adjudicated by the PEB and the initial VARD.  The CI was s/p partial removal of meniscus (semi-lunar cartilage) supporting a 10% rating under the code for symptomatic s/p removal of semilunar cartilage (5259) but this provides no rating benefit to the CI attained by consideration of §4.59 (painful motion) and §4.40 (functional loss).  There was no dislocated meniscus with locking to support rating consideration under VASRD diagnostic code 5258.  The Board next considered whether an additional separate rating for instability (5257) was supported in addition to the 10% rating for functional loss (§4.40)/painful motion (§4.59) as described above.  Although there was mild left knee ACL laxity (1+) after the surgery, the ligament graft was intact by MRI and by examination based on a firm end point on examination.  The VA C&P examinations following separation also did not document objective examination findings of instability.  Therefore the Board concluded there was not sufficient evidence for consideration of a rating under diagnostic code 5257 (other impairment, instability).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.

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 pain 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.

RECOMMENDATION:  The Board, therefore, recommends 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 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

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 XXXXXXXXXXXXXXXXX, AR20150007691 (PD201401692)

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:

Encl						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA