RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01745
BRANCH OF SERVICE:  Army	BOARD DATE:  20141008
SEPARATION DATE:  20080730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11C/Indirect Fire Infantry) medically separated for bilateral knee pain.  The knee pain condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The knee pain condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Hyperlipidemia was submitted by the MEB as medically acceptable.  The Informal PEB adjudicated “right knee pain” as unfitting at 10%, and “left knee pain” as unfitting at 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The hyperlipidemia condition was found not unfitting.  The CI made no appeals and was medically separated.

CI’s CONTENTION:  “Please consider all 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 ratings for the unfitting bilateral knee conditions are addressed below.  The hyperlipidemia condition is also addressed below. Any conditions outside the Board’s scope of review may be eligible for consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20080625	VA - (5 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5259	10%	Residual Of Right Knee Injury Status Post Anterior
Cruciate Ligament and Meniscectomy Repair	5260	10%	20080220	
Left Knee Pain	5099-5003	10%	Residuals Of Left Knee Anterior Horn Medial Meniscus
Tear 	5260	10%	20080220	
Hyperlipidemia	Not Unfitting	No VA Entry for Hyperlipidemia	
Other x 1 (Within Scope)	Other x 0	
Combined:  20%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20081230 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Right Knee.  In February 2006, the CI injured his right knee during a unit run.  He felt a “pop” and then his right knee gave out.  Magnetic resonance imaging (MRI) showed a torn anterior cruciate ligament (ACL), torn medial meniscus and a small tear of the lateral meniscus.  In April 2006, the CI had right knee surgery.  The ACL was reconstructed and a meniscus was removed.  In November 2006, he re-injured the right knee.  This necessitated a second surgery on the right knee.  Following that surgery, he continued to have problems and an MEB was initiated.

On 11 February 2008, 5 months prior to separation, the CI had a VA Compensation and Pension (C&P) exam.  He reported pain and stiffness of the right knee.  Aggravating factors were exercise, prolonged standing, prolonged sitting, running, walking or cold weather.  On physical examination (PE) of the knees, the right knee was normal in appearance.  There was some crepitus, but no tenderness to palpation (TTP).  Range-of-motion (ROM) was full and muscle strength was normal.  Lachman’s and McMurray’s tests were negative.  There was no ROM limitation from pain, fatigue, weakness or lack of endurance with repetitive use.

The MEB PE was performed on 13 February 2008.  At that exam, the CI complained of constant right knee pain, which worsened with driving, walking up steps, or prolonged standing.  He was able to walk up to two miles without significant pain, but was unable to complete the Army physical fitness test.  On PE of the right knee, there was no swelling or spasm.  Joint motion was normal, without any evidence of instability.  Lachman’s and McMurray’s tests were negative.  There was no demonstrated muscle weakness.  There was some medial TTP, with pain elicited on flexion and extension.  Mild laxity of the ACL was noted.  Sensation, coordination, gait, motor, balance, stance and reflexes were all normal.  The ROM evaluations which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Right Knee ROM
(Degrees)	PT ~ 6 mos. Pre-Sep
(20080123)	VA C&P ~ 5½ mos. Pre-Sep
(20080211)	
Flexion (140 Normal)	135	140	
Extension (0 Normal)	0	0	
§4.71a Rating	10%*	10%*	
                                         *10% based on VASRD §4.40 (Functional loss), and §4.45 (The joints)

The Board carefully reviewed all available evidence and directs attention to its rating recommendation.  The PEB and the VA chose different coding options for the right knee, but both assigned a disability rating of 10%.  The painful knee condition was essentially non-compensable based on the VASRD §4.71a diagnostic codes for loss of knee motion (5260 and 5261).  However; IAW VASRD §4.40 (functional loss) and §4.45 (the joints), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to painful motion of a major joint.  There was no path to a rating higher than 10% for the right knee since there was no evidence of ligamentous instability, subluxation or other significant joint abnormality.  After due deliberation, the Board determined that a disability rating of 10% was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic unfitting right knee pain.

Left Knee.  While recovering from his right knee surgery, the CI injured his left knee.  He suffered a medial meniscal tear, which was repaired on 20 September 2007.  At the 11 February 2008 C&P exam, he reported pain of the left knee.  An aggravating factor was walking up stairs.  On PE of the knees, the left knee was normal in appearance.  There was no TTP; ROM was full, and muscle strength was normal.  Lachman’s and McMurray’s tests were negative.  There was no ROM limitation from pain, fatigue, weakness or lack of endurance with repetitive use.

At the 13 February 2008 MEB physical examination, he complained of constant left knee pain, which was less severe that his right knee pain.  On PE of the left knee, there was no swelling or spasm.  Joint motion was normal, without any evidence of instability.  Lachman’s and McMurray’s tests were negative.  There was no demonstrated muscle weakness.  There was no TTP, but pain was elicited on flexion and extension.  Sensation, coordination, gait, motor, balance, stance, and reflexes were all normal.  The ROM evaluations which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Left Knee ROM
(Degrees)	PT ~ 6 mos. Pre-Sep
(20080123)	VA C&P ~ 5½ mos. Pre-Sep
(20080211)	
Flexion (140 Normal)	138	140	
Extension (0 Normal)	0	0	
§4.71a Rating	10%*	10%*	
                                         *10% based on VASRD §4.40 (Functional loss), and §4.45 (The joints)

Once again, the Board carefully reviewed all available evidence.  The Army PEB and the VA chose different coding options for the left knee, but both assigned a disability rating of 10%.  The painful knee condition was essentially non-compensable based on VASRD §4.71a diagnostic codes for loss of knee motion (5260 and 5261).  However; IAW VASRD §4.40 and §4.45, when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to painful motion of a major joint.  There was no path to a rating higher than 10% for the left knee since there was no evidence of ligamentous instability, subluxation, or other significant joint abnormality.  After due deliberation, the Board determined that a disability rating of 10% was appropriate.  Considering all of the evidence and mindful of VASRD §4.3, the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic unfitting left knee pain.

Other PEB Condition.  Hyperlipidemia was adjudicated by the PEB as not unfitting.  The Board’s main charge with respect to this condition is to assess the appropriateness of the PEB’s fitness adjudication.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  This condition was reviewed by the action officer and considered by the Board.  The Board noted that the hyperlipidemia was not profiled, was not mentioned in the commander’s statement, and was not specified as failing retention standards.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  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 hyperlipidemia condition.  Therefore, no additional disability ratings are recommended.

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 right knee pain and IAW VASRD §4.40 and §4.45, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee pain and IAW VASRD §4.40 and §4.45, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the hyperlipidemia condition, 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.

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 20140411, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150006328 (PD201401745)

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