RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-01713
BRANCH OF SERVICE:  Army	BOARD DATE:  20141119
SEPARATION DATE:  20040305

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reservist on temporary tour of active duty SPC/E-4 (13B1O/Field Artillery Cannon Crewmember) medically separated for right knee condition.  This condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Internal derangement of the right knee”, characterized as medically unacceptable, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “right anterior cruciate ligament (ACL) laxity” condition as unfitting, rated at 20%, with application of the Department of Defense Instruction (DoDI) 1332.39.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions 40%.”

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 right knee condition is addressed below.  There are no additional conditions within the DoDI 6040.44 defined purview of the Board.  Any condition 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.

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 VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20040206	VA* - (2.7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Anterior Cruciate Ligament Laxity	5257	20%	Anterior Cruciate Ligament Tear…Right Knee	5257-5261	10%	20040525	
Other x 0 (Not in Scope)	Other x 2	
Combined:  20%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20061023 (most proximate to date of separation)

ANALYSIS SUMMARY:

Right Knee Condition.  The CI originally injured his right knee while playing basketball in February 2003.  He described a twisting type injury causing pain and feeling of instability.  A magnetic resonance image performed in March 2003 revealed joint bruising, an incomplete meniscal tear and a complete ACL tear.  Orthopedic examination performed in July 2003 noted full right knee range-of-motion (ROM), the absence of effusion, a “stable” leg with a positive anterior drawer test (a test possibly indicating a degree of instability).  He continued to have pain especially with stair climbing.  Surgical correction was recommended and was declined by the CI…stating fear of unsuccessful results.  His primary treatment modality remained physical therapy.  

At the narrative summary (NARSUM) examination performed on 14 November 2003 (4 months prior to separation), the CI endorsed right knee pain aggravated by running, negotiating stairs, deep squatting or heavy lifting.  The physical examination (PE) revealed the CI wearing a knee brace.  His instability tests were positive and described as “slight laxity.”  ROM was decreased without comment on the presence of painful motion.  There was no effusion, edema or erythema present.  The frequency and severity of pain was described as “occasional” and “minimal,” respectively.  His diagnosis was internal derangement of the right knee.  The commander’s statement indicated the CI’s impairment as negatively impacting the performance of his duties by preventing completion of MOS requirements.  The permanent profile listed ACL deficient, right knee as the sole diagnosis.  

At the VA Compensation and Pension examination performed on 25 May 2004; 6 weeks after separation, the CI reported minimally vague symptoms of intermittent (non-daily) aching right knee pain aggravated with kneeling, squatting, weight bearing or extreme temperature exposure and relieved with rest and pain meds.  He denied weakness, stiffness, or limitations of activities of daily living.  The PE was detailed and revealed a normal gait with non-painful limited ROM.  The drawer test was positive without end-point description; all other stability tests were negative.  The CI’s diagnosis was stated per historical radiology reports of ACL tear with an additional comment of “residual instability present.”

The goniometric 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.

Right Knee ROM
(Degrees)	NARSUM 3.7 Mo. Pre-Sep
(20031114) 	VA C&P 2.7 Mo. Post-Sep
(20040525) 	
Flexion (140 Normal)	105	112	
Extension (0 Normal)	0	- 12	
Comment	(+) laxity 	(+) laxity	
§4.71a Rating	10%-20% (PEB 20%)	 20% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  Although the service and VA titled the unfitting back condition slightly different they both utilized (in various combinations) the code of 5257 (knee; other impairment); singularly by the PEB and dual coded with 5261 (limited extension) by the VA.  Board members first agreed that the central core of this case were the persistent findings of knee laxity coupled with corresponding X-ray evidence of a complete ACL tear.  Members deliberated on the level of laxity impairment.  Code 5257 criterion is categorized into three levels of “slight” (10%), “moderate” (20%), and “severe” (30%) impairment.  Board members considered and agreed that in light of the NARSUM’s description of “slight laxity” coupled with the VA’s finding of a normal gait without ADL limitations, the CI’s condition is best supported at the “slight” (10%) level of instability.  The Board also discussed and agreed that additional limitation of motion in knee extension meets the compensable 10% level under 5261.  Absent greater instability, boney pathology, or worsening evidence of limited ROM, the Board agreed that there were no available alternative joint or analogous coding options which are applicable and or advantageous to the CI’s current 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that although there are alternate coding pathways available, none would result in a higher rating currently applied by the PEB; and therefore, does recommend a change in the PEB’s  adjudication for the right 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.  As discussed above, PEB reliance on DoDI 1332.39 for rating the right knee was operant in this case and the condition was adjudicated independently of that policy.  In the matter of the right 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.

RECOMMENDATION:  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 20140310, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXX
President
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, AR20150006267 (PD201401713)

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