RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01726
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Petroleum Supply Specialist, medically separated for “left knee plica syndrome,” with a disability rating of 10%.

CI CONTENTION:  The applicant request consideration of his remaining MEB conditions.   The remaining conditions are addressed in “Scope of Review” below.   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 - 20090617	VARD - 20090914	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Plica Syndrome Diagnosed as Arthritis	5099-5003	10%	Patellar Chondromalacia, Left Knee	5014-5260	10%	20090909	
Atypical Gastroesophageal Reflux Disease	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Knee Plica Syndrome.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in July 2008 after he slipped and fell from a 5-ton truck and sustained blunt trauma to the left knee.  Radiographic studies in September 2008 showed a moderate joint effusion (fluid within the joint), but no fracture or fracture-related deformity and no degenerative or erosive changes.  Because of some noted soft tissue edema (swelling possibly due to fluid accumulation) the radiologist had concern for internal derangement and recommended a magnetic resonance imaging (MRI) examination.  An MRI conducted in November 2008 showed all ligaments and menisci supporting the knee as intact; an essentially unremarkable examination. Despite further conservative treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military occupational specialty and he was referred for a MEB.  

At the time of the Physical Therapy clinic appointment on 19 December 2008, 8 months prior to separation, the examiner recorded a slow, steady, mildly antalgic gait.  The CI was able to perform a ¾ uncompensated squat with left knee pain, single leg stance of > 45 seconds on the left, and 5 single leg hops with pain at the joint line on the left.  All tests for stability were negative.  There was a positive McMurrays test (possible sign of meniscal/knee cartilage damage).  The examiner elicited “screams (loud) and… nearly jumps off the table with applied overpressure in flexion” leading the examiner to document a “high suspicion of symptom magnification”.   At the MEB examination dated 9 March 2009, 5 months prior to separation, the physical examination recorded that the CI’s left knee appeared grossly normal with zero deformity or injury.  The CI exhibited minimal guarding with his left knee.  He wore a large hinged brace on the knee.  There was minimal retropatellar (behind the knee cap) fluid with some apprehension, no joint line tenderness but tenderness to palpation on patellar (knee cap) compression.  Stability tests were negative. There was 5/5 strength and 2/4 deep tendon reflexes of the lower extremities.  

At the VA Compensation and Pension (C&P) examination on 9 September 2009, performed a month after separation, physical exam demonstrated an antalgic gait, left knee crepitation, sub-patellar tenderness, and painful motion.  There was 5/5 muscle strength bilaterally and no instability.  The examiner recorded.  Repetitive ROM testing (DeLuca criteria) showed objective evidence of pain with repetition, but no additional limitation of motion. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous code 5099-5003 (degenerative arthritis), citing satisfactory evidence of painful motion.  The VA also assigned a 10% rating using codes 5014-5260 (osteomalacia-limitation of flexion) based on the VA C&P examination a month after separation, citing objective evidence of painful limitation of motion of a major joint.  There was no limitation of motion which attained a minimum 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), frequent locking with effusions or any indication of dislocated meniscus or loose body (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).  There is therefore 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 left knee plica syndrome condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the CI’s atypical gastroesophageal reflux diseases (GERD) condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The atypical GERD condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.   The atypical GERD condition was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation 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 contended atypical GERD condition and so no additional disability rating is recommended.

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.  In the matter of the contended atypical GERD condition, the Board unanimously recommends no change from the PEB determinations 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

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 XXXXXXXXXXXXXXXXXXXX, AR20160006820 (PD201401726)

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