RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01771
BRANCH OF SERVICE:  Army	BOARD DATE:  20141204
SEPARATION DATE:  20070504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army PV2/E-2 (68W/Health Care Specialist) medically separated for partial tear left posterior cruciate ligament (PCL).  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty; however, his profile indicated he could take an alternate physical training test.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “left knee pain secondary to medial collateral ligament (MCL) sprain with partial tear to the posterior cruciate ligament, pain is moderate and frequent,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions, “acute stress disorder,” “pulmonary granulomatous disease,” and “chronic neck pain,” as medically acceptable.  The Informal PEB adjudicated “partial tear of left posterior cruciate ligament with medial collateral ligament sprain,” as unfitting, rated at 0% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI 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 rating for the unfitting left knee condition is addressed below; as well as the three conditions (acute stress disorder, lung granuloma, and chronic neck pain) that were determined to be unfitting by the PEB.  No other 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 20070420	VA - (8 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Partial Tear of Posterior Cruciate Ligament with Medial Collateral Ligament Sprain, Left Knee	5257	0%	Laxity, Medial Collateral Ligament, Left Knee	5257	20%	20080109	
			Medial Collateral Ligament Sprain with Partial Tear to the Posterior Cruciate Ligament	5299-5260	10%	20080109	
Acute Stress Disorder 	Not Unfit	Major Depressive Disorder	9434	30%	20070505	
Lung Granuloma 	Not Unfit	Granuloma, Right Lung	6899-6820	0%	20080109	
Chronic Neck Pain	Not Unfit	Chronic Neck Pain	5237	NSC	20080109	
Other x 0  (Not in Scope)	Other x 0 		
Combined:  0%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20080514 (most proximate to date of separation)

ANALYSIS SUMMARY:

Partial Tear of Posterior Cruciate Ligament with Medial Collateral Ligament Sprain, 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 ~ 1 Mo. Pre-Sep
(20070404)	
MEB ~1 Mo. Pre-Sep
(20070406)
	PT ~1 Mo. Pre-Sep
(20070413)	VA C&P ~8 Mo. Post-Sep
(20080109)	
Flexion (140 Normal)	0-110	97 	110	118	
Extension (0 Normal)	0	10 	0	0	
Comment	Active ROM
No ligament instability
McMurray negative	ROMs reported at pain onset 
Total ROM 107 - indicating full extension
No ligament instability
Pain with McMurray	25Apr07 PT exam also extension 0, flex 115	Pain at 115 degrees
Cruciate ligaments tight
Medial collateral ligament is lax.  
McMurry “positive”	
§4.71a Rating*	10%	10%	10%	10%	
*10% with application of painful motion §5.59 / functional loss §4.40

According to the MEB narrative summary (NARSUM) and service treatment records (STRs), the CI injured his left knee in February 2007.  An magnetic resonance imaging (MRI) performed on 25 March 2007, demonstrated an area of abnormal high signal in the PCL indicating a partial tear (some fibers) but the ligament was otherwise intact.  There was a fluid collection in the joint (effusion) consistent with a recent injury and some mild degenerative change of the knee cap (chondromalacia patella).  At the time of orthopedic evaluation on 4 April 2007, knee pain and swelling had decreased but the CI reported persistent pain with impact activities.  There was tenderness but no swelling or effusion (fluid in the knee).  The McMurray test for meniscus problems was negative.  On examination, active ROM was good with full extension (see chart).  All ligaments were intact and stable on examination including the PCL (the injured ligament), anterior cruciate ligament and medial and lateral collateral ligaments.  The orthopedic surgeon diagnosed a left knee PCL sprain and MCL sprain with stable physical examination.  

The MEB NARSUM prepared on 6 April 2007 described the ROM for the left knee recorded on the chart above.  The NARSUM noted no ligament instability including the anterior and PCLs and the medial and lateral collateral ligaments.  There was pain during evaluation of ROM and stress of the meniscus.  The NARSUM author documented there was minimal effusion and use of a knee brace for ambulation.  Physical therapy examinations on 13 April 2007 and 25 April 2007 documented normal extension and mild limited flexion consistent with other examinations.  Approximately 2 months following separation, the CI was evaluated by another orthopedic surgeon who obtained a new MRI scan.  The MRI showed evidence of a gastrocnemius muscle strain, a possible intercondylar fracture and a possible medial meniscus injury without tear.  The cruciate ligaments were intact and normal in appearance and the MCL was intact.  There was no evidence of chondromalacia.  On July 18, 2007, the CI underwent examination of the left knee under anesthesia and arthroscopic surgery.  No finding of joint instability was described from the examination under anesthesia.  On arthroscopic examination, there were no arthritic changes or meniscus tears and the ligaments were intact.  The only abnormality found during arthroscopy was a “very large” pre-patellar band of tissue, (plica) that was removed (plica are developmental structures that persist in up to 50% of individuals and can cause pain in runners or athletes.  Surgery is usually curative).  A post-operative note dated 3 August 2007 noted that “He is doing real well.  His leg feels great and he still needs to work on his muscle tone.  He has minimal swelling and his activity level is good.”  The orthopedic surgeon prepared a note on 3 August 2007 for the CI’s use, “Mr. ____ has had an excellent recovery from his left knee surgery and he is making excellent progress.  After another month of rehab on his quads, he should be able to participate in all National Guard Duties without any limitation.”

At the VA Compensation and Pension (C&P) examination dated 9 October 2008 (8 months after separation) the CI reported his knee pain was much improved since surgery but reported persistent pain with activity.  There was no locking, but the CI reported once per week give way symptoms due to weakness.  He no longer used a brace.  On examination, there was mild swelling and effusion.  ROM demonstrated full extension and mild limitation of flexion similar to prior exams (see chart).  The cruciate ligaments (anterior and posterior) were “tight.”  The MCL was “moderately lax” (ligament on the inside aspect of the knee).  There was pain with repetitive motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated a rating of 0% using code 5257 (other impairment of the knee, recurrent subluxation or lateral instability) noting the absence of PCL instability.  The VA granted a 20% rating for MCL laxity of the left knee, coded 5257, citing the moderate laxity of the medial collateral ligament reported at the time of the post separation VA C&P examination.  The VA granted an additional 10% rating for medial collateral ligament sprain with partial tear of the PCL as analogous code 5299-5260 (limitation of flexion), citing §4.59 (painful motion) and §4.40 (functional loss).  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 5260 (limitation of flexion) or 5261 (limitation of extension).  The MEB NARSUM reported pain at 10 degrees of extension and 97 degrees of flexion with a total ROM of 107 degrees indicating full extension consistent with other examinations.  There was no described finding of a meniscal tear during surgery to support a rating consideration under VASRD diagnostic code 5258 dislocated meniscus with frequent locking.  There was no removal or repair of the meniscus described during surgery to support a rating under code 5259 symptomatic meniscus after removal.  Although the initial MRI demonstrated increase signal indicative of a partial tear of the PCL, there was no laxity or instability of that ligament to support a minimum rating under 5257.  The post separation MRI did not report any abnormality of the PCL and orthopedic examination and arthroscopy did not show any abnormality of the PCL.  The Board noted the VA C&P examination report of moderate laxity of the medial collateral ligament upon which the VA based its 20% rating under VASRD code 5257.  However, the MRI and orthopedic evaluation prior to separation did not demonstrate any injury or laxity of the MCL.  The MRI and orthopedic evaluation 2 months after separation also did not demonstrate any injury or laxity of the MCL, or any other ligament (anterior cruciate, posterior cruciate, lateral collateral, medial collateral).  Therefore, the Board concluded there was not sufficient evidence of objective examination findings of instability for consideration of a rating under diagnostic code 5257 (other impairment, instability).  All Board members agreed that the examinations summarized above reported sufficient evidence of painful motion and functional loss due to knee pain to support a 10% rating (§4.59 and §4.40).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the partial tear of PCL with medial collateral ligament sprain, left knee condition as code 5299-5260.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the acute stress disorder, lung granuloma and chronic neck pain were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Acute Stress Disorder.  According to STRs, the CI’s wife was diagnosed with cancer and underwent surgery while he was in basic training.  The tumor recurred and she was to undergo chemotherapy.  The CI presented to the mental health clinic on 12 February 2007 with the chief complaint of “I cannot handle the anxieties and depression of being away from [my] sick wife (cancer).”  The examiner noted, “The patient feels very guilty about his decision to join the Army, does not want to quit but believes that his first and immediate priority is to be with his wife.”  The psychiatrist diagnosed acute stress disorder and offered the CI counselling.  The acute stress disorder was not profiled.  In an e-mail dated 5 April 2007, the psychiatrist stated the acute stress disorder was not medically disqualifying.  The final profile was written by a psychiatrist and the stress condition was not profiled.  The commander’s comments did not include the acute stress disorder as a medical condition affecting the CI’s performance of his mission.  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 acute stress disorder and, therefore, no additional disability rating can be recommended.

Cervical Neck Pain.  The CI sustained an injury to his cervical spine in a motor vehicle crash prior to entering military service (STRs record CI report the injury was in 2005, while the VA C&P examination on 9 January 2008 records the injury occurred in 2000).  The CI was seen twice in the clinic on 16 February 2007 for complaints of chronic neck pain of 2 years duration.  No injury while in service was noted.  X-rays were normal.  The MEB physical completed in April 2007 of the spine described “neck supple.”  The MEB NARSUM noted chronic neck pain as a diagnosis that was medically acceptable.  There was no performance based evidence from the STR that this condition significantly interfered with satisfactory duty performance.  The final profile did not include neck spine pain as a medical condition limiting functional mission activities or deploying.  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 of medically fit for the chronic cervical spine condition.

Lung Granuloma.  A routine screening chest X-ray for the MEB process was noted to show a possible abnormal spot.  Computed axial tomography (CAT scan) of the lungs noted calcified granuloma (small spots of scar tissue) and calcified lymph nodes consistent with old healed granulomatous disease (prior infection).  The CI was asymptomatic and there were no service treatment record entries for respiratory symptoms.  On the DD Form 2807, Report of Medical Examination, dated 27 March 2007, the CI checked yes to shortness of breath, however this was referring to a time prior to entry into military service when he underwent an evaluation for heart disease in 2003.  The NARSUM listed the lung granuloma disease as a diagnosis noting that it was medically acceptable for military duty.  The final profile did not include a lung condition as a functionally limiting medical condition.  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 of medically fit for the lung granulomatous 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.  In the matter of the partial tear of PCL with MCL sprain, left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5260 IAW VASRD §4.71a.  In the matter of the contended the acute stress disorder, lung granuloma and chronic neck pain 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.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Partial Tear of Left Posterior Cruciate Ligament	5299-5260	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140424, 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, AR20150008238 (PD201401771)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		     XXXXXXXXXXXXXXX
		     Deputy Assistant Secretary of the Army
		         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA