RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01784
BRANCH OF SERVICE:  Army	SepAration date:  20030604

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (SIGINT Analyst) medically separated for chronic right knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for an Medical Evaluation Board (MEB).  Right knee chondromalacia and bilateral plantar fasciitis were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded bilateral hamstring tightness and obstructive sleep apnea severe for PEB adjudication.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated chronic right knee pain as unfitting, rated 0% with 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:  Requests all not-unfitting MEB conditions re-adjudicated and considered not unfitting for duty.  His complete submission is at Exhibit A.

RATING COMPARISON:

IPEB – Dated 20030306	VA* - (~6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5099-5003	0%	Internal Derangement Right Knee	5257-5010	10%	20031202	
Bilateral Plantar Fasciitis	Not Unfitting	No VA Placement	
Bilateral Hamstring Tightness	Not Unfitting	… Pain In Both Hamstrings …	5299-5010	NSC	20031202	
OSA	Not Unfitting	Sleep Apnea	6847	50%	20031202	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 9	
RATING:  0%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20040109 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Right Knee Condition.  The service treatment record (STR) documents that the CI sustained a right knee twisting injury while playing basketball.  He underwent an arthroscopic reconstruction of his right anterior cruciate ligament (ACL) with a hamstring graft, debridement (surgical excision of damaged, devitalized, or contaminated tissue or foreign matter) of a medial meniscal tear, and chondroplasty (surgical repair of cartilage) of a lateral femoral condyle defect.  A right knee MRI, 18 months postoperatively, showed postsurgical changes, and no evidence of complete disruption of the ACL graft.  There was evidence of a partial tear of the posterior cruciate ligament (PCL), probable tears of the residual menisci, a bony body at the posterior knee (possible loose body), early osteoarthritis and moderate to severe chondromalacia (abnormal cartilage softening or degeneration).  The MEB narrative summary (NARSUM) by orthopedic surgery, 9 months before separation, recounted the history and interventions.  The CI initially did well postoperatively but felt a “pop” in his right knee approximately 6 months after surgery.  He subsequently began having pain, stiffness and mechanical complaints.  The CI complained of grinding, clicking, and popping but denied true locking.  The right knee pain prevented heavy activity and running but the CI was able to perform low impact exercises such as cross trainers.  He had no lasting relief from non-operative modalities to include activity modification, physical therapy (PT), and nonsteroidal anti-inflammatory drugs (NSAIDs).  The right knee exam revealed no effusion (fluid collection) and minimal posterior medial joint line tenderness.  There was significant crepitus (grating sound or sensation) but the patella appeared to track normally.  There was no instability or ligamentous laxity by valgus/varus stress (assesses medial/lateral collateral ligaments), Lachman (assesses ACL instability), pivot shift (assesses ACL instability), or anterior/posterior drawer (assesses ACL/PCL instability) tests.  The range-of-motion (ROM) was 0 to 110 degrees of flexion (normal extension 0 to 140 flexion).  The surgeon opined that operative interventions were unlikely to provide near or complete relief of his right knee pain.  The diagnosis listed moderate to severe right knee chondromalacia that appeared refractory to non-operative management.

The VA Compensation and Pension (C&P) joint exam, 6 months after separation, recounted the history and interventions.  The CI complained of intermittent pain and swelling in both knees, right greater than left.  The CI reported that the right knee surgery to repair the torn ACL provided no relief.  Pain was exacerbated by prolonged sitting and “bad weather” and relieved by stretching.  The examiner documented that the most recent right knee MRI showed a torn PCL.  The CI took no pain medication but had been forced to avoid most strenuous activities.  The physical exam revealed a normal gait (native, heel, toe gaits).  The CI was able to hop normally on either foot and squat normally.  The right knee had a well-healed surgical incision (2-inch) inferiorly and medially.  The bilateral knee exam showed mild to moderate crepitus on extension.  There was no swelling, fluid, heat, eryrthema (redness), tenderness, subluxation (incomplete or partial dislocation), or contracture (distortion of muscular or connective tissue due to spasm, scar, or paralysis).  There no was laxity or instability and the McMurray (assesses meniscus dislocation) tests were negative.  The ROM was extension of 0 and flexion of 130 degrees on the right and extension of 0 and flexion of 135 degrees on the left.  There was no evidence of weakened movement, excess fatigability, or incoordination or that these factors decreased motion.  There was no evidence that pain decreased motion.  Motor function, sensation, and deep tendon reflexes were normal.  The diagnosis listed internal derangement of both knees (right greater than left) status post right knee surgery.

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB, rated the right knee condition at 0% with code 5099-5003 (Analogous for arthritis, degenerative).  The PEB cited chronic knee pain status-post surgery, chondromalacia, negative Lachman's, full ROM, and rated at 0% as only one joint involved.  The VA rating decision (VARD), cited the C&P exams 6 months after separation, rated the right knee condition at 10% with codes 5257-5010 (Knee, other impairment and arthritis, due to trauma).  The VARD cited slight limitation of motion and no instability.  The proximate (MEB NARSUM and C&P) exams did not demonstrate limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  While the CI underwent a debridement of a medial meniscal tear, there was no dislocated meniscus (5258), or symptomatic removed meniscus (5259), to support a minimum rating under the respective codes.  There was no ankylosis (5256) or instability (5257) to support a minimum rating under the respective codes.  The Board agreed a 10% rating was supported based on functional loss (§4.40) or painful motion (§4.59).  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 right knee condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral plantar fasciitis, bilateral hamstring tightness, and obstructive sleep apnea (OSA) conditions 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.

Contended Bilateral Plantar Fasciitis Condition.  The NARSUM documents that the bilateral plantar fasciitis (right greater than left) was chronic in nature and had not improved with inserts.  The CI stated that it was not performance limiting and that he may still be able to perform at a high level despite his feet.  The NARSUM examiner documented that the bilateral plantar fasciitis met the standards of medical fitness and did not interfere with satisfactory performance of military duties.  While the bilateral plantar fasciitis was listed as medically unacceptable by the MEB, it was not profiled, not implicated in the commander’s statement, and was considered to be not unfitting by the PEB.

Contended Bilateral Hamstring Tightness Condition.  In the NARSUM, the CI stated his bilateral hamstring tightness was not activity limiting as he did not have problems until he exercised at an intense level.  The NARSUM examiner documented that the bilateral hamstring tightness met criteria for retention.  The bilateral hamstring tightness was not profiled, not implicated in the commander’s statement, was medically acceptable by the MEB, and was considered to be not unfitting by the PEB.

Contended OSA Condition.  The STR documented the CI’s initial sleep study (polysomnogram) referral 7 months prior to separation.  This study diagnosed obstructive sleep apnea (OSA) and suggested therapeutic options of CPAP, surgery, or an oral appliance.  The CI elected for a trial of CPAP.  Prior to this sleep study the STR contained scant documentation of the typical clinical manifestations of OSA (fatigue, daytime sleepiness, loud snoring, nocturnal gasping, nocturnal choking, restless sleep, poor concentration, or morning headaches).  The NARSUM, 1 month before the polysomnogram, contained no history of snoring, apnea (cessation of breathing), excessive daytime sleepiness, or fatigue.  OSA was not examined or diagnosed by the NARSUM examiner.  A letter from the sleep disorders center documented that the CI was committed to using nasal CPAP, but experienced some difficulty adjusting to it.  His CPAP compliance was moderately poor, but appeared to be improving.  The CI expressed no interest in pursuing surgical interventions for the OSA.  The CI was obtaining an oral dental device for the treatment of OSA.  While the OSA was profiled and listed as medically unacceptable by the MEB, it was not implicated in the commander’s statement, and was considered to be not unfitting by the PEB.

All contended conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  The Board determined that the preponderance of evidence indicated that these conditions were not unfitting for continued military service.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the bilateral plantar fasciitis, bilateral hamstring tightness, and OSA conditions and so 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 condition, the Board unanimously recommends a disability rating of 10%, coded 5257-5010 IAW VASRD §4.71a.  In the matter of the contended bilateral plantar fasciitis, bilateral hamstring tightness, and OSA conditions, 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:

CONDITION	VASRD CODE	RATING	
Chronic Right Knee Pain	5257-5010	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

SAMR-RB

0 6 JUL 2016

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 XXXXXXXXXXXXXXXXXX, AR20160003390 (PD201401784)

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,
accept the Board's recommendation to modify the individual's disability rating to 10%
without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA