RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-01857
BRANCH OF SERVICE:  Army	BOARD DATE:  20141010
SEPARATION DATE:  20040815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63S/Heavy Wheel Mechanic) medically separated for a left knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) but he could perform an alternate physical fitness test.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The chronic left knee condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Additionally, a symptomatic pes planus condition was also submitted by the MEB.  The Informal PEB adjudicated “chronic left knee pain” as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The symptomatic pes planus was determined to be not unfitting by the PEB.  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; additionally the symptomatic pes planus condition is also 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 20040524	VA - (8 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5261	20%	Residuals of Tear Anterior Cruciate Ligament, Left Knee,
S/P Repair w/Degenerative Joint Disease	5260	10%	20050307	
Symptomatic Pes Planus	Not Unfitting	Bilateral Pes Planus	5276	10%	20050307	
Other x 1 (Within Scope)	Other x 1	
Rating:  20%	Combined:  30%	
 Derived from VA Rating Decision (VARD) dated 20050418 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Left Knee Pain Condition.  On November 2001, while on a ruck march, the CI stepped into a hole and twisted his left knee.  Persistent pain ultimately led to a diagnosis of an anterior cruciate ligament (ACL) and medial meniscal (cartilage) tears.  In November 2002, surgical reconstruction of the ACL and debridement of the medial meniscal tear was performed.  Despite physical therapy, pain and decreased range of motion (ROM) persisted.  Arthroscopic surgery was offered as a means of correcting suspected arthrofibrosis (scarring) of the graft site, but was declined by the CI since improvement could not be guaranteed.

The narrative summary on 14 April 2004 (4 months prior to separation) noted the CI was unable to climb on and off military vehicles, carry heavy items, run or jump.  Prolonged standing was painful.  Examination noted an antalgic gait (limping) that favored the right side.  There was swelling of the left knee that obscured bony prominences.   Strength of the left lower extremity was normal.  Testing maneuvers for left knee ligament stability were normal.  X-ray showed mild osteoarthritis.

At the VA Compensation and Pension exam on 7 March 2005 (8 months after separation) the CI reported chronic pain in the left knee joint with flare-ups from prolonged walking, going up and down stairs or trying to squat.  He sometimes took Tylenol for pain, but it is not clear if this was for the knee or feet.  He was looking for a job, having left his previous job 2 months previously for unstated reasons.  He had no incapacitating episodes in the past 12 months relevant to the left knee pain and was able to walk and drive.  He could not walk or run long distances.  Physical examination noted he had an antalgic gait with mild limping due to knee pain.  He did not use an assistive device.  The left knee had a normal appearance with no swelling and with a well-healed surgical scar.  All ligaments were tested and were stable.  Repetitive motion in the left knee joint resulted in increased pain, easy fatigue, lack of endurance, and decreased left knee ROM by 5 to 10 degrees.  X-rays showed postsurgical hardware and degenerative joint disease of the left knee.

The goniometric 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)	MEB ~ 4 Mo. Pre-Sep	VA C&P 7 Mo. Post-Sep	
Flexion (140 Normal)	90	125	
Extension (0 Normal)	15	0	
Comment	+Painful motion	+Tenderness, painful motion, crepitation	
§4.71a Rating	20%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB assigned a rating of 20%, coded 5261 (leg, limitation of extension of).  The VA rated the condition at 10% under the 5260 code (leg, limitation of flexion); because limitation of flexion was non-compensable, the VA cited VASRD §4.40 (functional loss) as a rationale for the rating decision.  The Board agreed that the PEB’s 20% rating was justified based on extension limited to 15 degrees on the MEB exam.  Routes to a higher rating were considered, but the alternate knee codes 5257 (knee, other impairment of), 5258 (cartilage, dislocated) and 5259 (cartilage, removal of) provided no such avenue.  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 chronic left knee pain condition.

Contended PEB Condition. The Board’s main charge is to assess the fairness of the PEB’s determination that symptomatic pes planus (flat feet) was 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.  Review of the service treatment record showed one visit to podiatry in April 2004 for “pain mostly in the left foot.”  Custom orthotics were prescribed for the pes planus condition.  The MEB separation exam indicated that the CI had symptomatic pes planus, left worse than right, which was determined by podiatry to meet retention standards.
The pes planus condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The 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, 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 symptomatic pes planus and no additional disability rating is 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 chronic left knee pain condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended symptomatic pes planus 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 20140424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150006355 (PD201401857)

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						     XXXXXXXXXXXXXXXXX