RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01832
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E5, Wheeled Vehicle Mechanic, medically separated for “chronic left knee pain status post anterior cruciate ligament reconstruction,” with a disability rating of 10%.  

CI CONTENTION:  The CI contended that his condition should have been reviewed IAW the VASRD instead of DoDI 1332.39.  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 - 20100423	VARD - 20100423	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5010	10%	…ACL Tear, Left Knee…	5010-5260	10%	20100309	
Chronic Right Foot Plantar Fasciitis	Not Unfitting	No VA Entry	
Primary Insomnia	Not Unfitting		
Hypercholesterolemia	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary, the CI underwent left knee surgery in February 2008 for torn anterior cruciate ligament (ACL).  Multiple follow-up orthopedic evaluations after surgery noted the knee was stable.  The CI underwent a second surgery in December 2008 which he reported was to remove scar tissue.  The CI’s knee pain persisted and X-rays on 12 January 2009 noted post-surgical changes and mild joint space narrowing.  Despite treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and so he was referred for a MEB

At the MEB examination (recorded on DD Form 2807 and 2808), dated 14 January 2009 (7 months prior to separation), the CI reported that he wore a knee brace to support his left knee. The examiner noted that the CI had a well-healed scar, full active ROM with pain at the end range and tenderness.  Examination tests for ligamentous instability and meniscus pathology were negative.  At the MEB orthopedic consultation dated 14 January 2009 (7 months prior to separation), the CI reported persistent popping and pain in his left knee.  The examiner noted mild tenderness and “1A Lachman” (small degree of anterior movement with stability testing, with a firm end point).  The CI had near full ROM “with no pain at maximum flexion.”  Magnetic resonance imaging of the knee demonstrated that surgical hardware was in place and that the CI had an intact ACL graft with no meniscal (semilunar cartilage) or joint cartilage (chondral) pathology.  The MEB examiner indicated that the CI’s knee was stable and his problems were pain related.

At the VA Compensation and Pension (C&P) examination, dated 9 March 2010 (7 months after separation), the CI reported that his left knee pain was aggravated by activity and standing for extended periods of time, but he had no problem with walking.  He also reported that he could no longer perform the heavy lifting or tolerate the vibrations from operating the heavy equipment associated with his civilian job.  The physical exam showed a normal gait.  The knee was normal in appearance with well healed surgical scars.  Examination tests for ligamentous instability and meniscus pathology were negative.  He had normal ROM, but after repetitive use, he had pain, fatigue, weakness, and lack of endurance “with pain being the major factor.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5010 (arthritis due to trauma), citing painful motion.  The VA rated the left knee condition 10%, coded 5010-5260 (limitation of flexion), citing “evidence of pain, fatigue, weakness and lack of endurance upon repeated range of motion exercises,” based on the post-separation C&P examination.  

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.  Similarly, a 10% rating is supported coded as 5003 for limited motion of a single major joint with imaging evidence of degenerative arthritis.  The Board reviewed to see if a higher rating was achieved with any applicable code.  However, there was no evidence of residual instability following the ACL repair ratable under diagnostic code 5257.  The “1A Lachman,” noted at the orthopedic consult above reflects a small degree of anterior movement with stability testing, with a firm end point, which indicates an intact ACL.  The MEB and C&P exams noted no significant instability on testing.  There was no 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 condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right plantar fasciitis, primary insomnia, and hypercholesterolemia were 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 right plantar fasciitis, primary insomnia, and hypercholesterolemia were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All 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.  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 any of the contended conditions and so no additional disability ratings are 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 right plantar fasciitis, primary insomnia, and hypercholesterolemia 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.  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 20140416, 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, AR20160006827   (PD201401832)

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