RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02085
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “chronic pain, right knee,” with a disability rating of 10%  

CI CONTENTION:  “Please consider all conditions.”  The CI’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 - 20030609	VARD - 20040412	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Knee	5099-5003	10%	Degenerative Joint Disease and Chondromalacia, Right Knee	5010	20%	20031202	
Chronic Right Shoulder Pain	Not Unfitting	Rotator Cuff Tendonitis and Acromioclavicular Separation, Right Shoulder	5203	20%	20031202	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Pain, Right Knee.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI twisted his right knee on the day he was due to return to basic training after rehabilitation of bilateral foot and ankle injuries (possible stress fractures) incurred earlier.  Magnetic resonance imaging (MRI) demonstrated bone bruises (lateral tibia plateau and femoral condyle), a partial tear versus strain of the anterior cruciate ligament (ACL), and chondromalacia patella (damage to the cartilage under the knee cap).  All menisci and remaining ligaments were intact.  Orthopedics opined that surgery was not indicated.  Earlier STR entries indicated guarded range of motion (ROM) with significant limitations of flexion, but none meeting the VASRD §4.71a minimum 10% rating thresholds (flexion 45 degrees or extension minus 10 degrees).  One entry noted equivocal signs of anterior instability (Lachman’s) and impingement (McMurray’s); but, the remainder (including the orthopedic entries) documented stability to stress testing, no signs of impingement (locking), and no consistent effusion.  There were conflicting STR entries regarding gait disturbance and the use of assistive devices and these were confounded by concurrent complaints of foot and ankle pain.  

Despite conservative treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic right knee pain” for PEB adjudication.   

The MEB NARSUM examination on 8 May 2003 (2 months before separation) rated the pain as “slight ... [and] ... frequent” and documented functional impairments linked to general soldiering requirements.  There was no documentation of subjective instability or locking.  The physical examination (no comment regarding gait) recorded tenderness, the absence of effusion or atrophy, stability to stress testing, and negative signs of impingement.  The examiner documented “full” passive ROM and stated that active flexion was limited to 80 degrees “because of pain,” making additional note of “an exaggerated pain response.”

The 2 December 2003 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, documented persistent pain that limited bending and prohibited squatting.  The examiner further stated that “the physical findings that we see do not correlate with the intensity of his complaints.”  The physical examination (no comment regarding gait) recorded “mild popping,” the absence of effusion, negative signs of impingement, negative anterior (ACL) instability, but “mild medial and lateral weakness on stressing.”  Normal ROM measurements were provided (flexion 140 degrees, extension 0 degrees) without comment regarding painful motion.  The examiner opined that the condition “could cause weakened motion and fatigue due to pain ... [ROM] would be decreased with exacerbation with increased use.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5099-5003 code (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA assigned a 20% rating using the 5010 code (arthritis due to trauma), citing “10 percent is assigned for arthritic findings and limited [ROM] during flare-ups along with an additional 10 percent for evidence of knee weakness.”  It was unclear whether the additional 10% was premised on instability based on the C&P findings of mild medial and lateral laxity, although that would properly be reflected by a separate rating under code 5257; or, if it were intended as additional rating premised on DeLuca concession to the C&P examiner’s opinion.  Members agreed, however, that additional rating under DeLuca provisions was not supported by the evidence.  The VA examiner’s opinion was purely speculative with no ROM or strength examinations performed after repetitions.  Members further agreed that a separate rating for instability was not supported by the majority of objective evidence in this case.  There was no ROM limitation in evidence meeting the minimum compensable threshold of any applicable code.  The C&P finding of mild medial and lateral laxity was not corroborated by any other examiner; and, there was MRI confirmation of intact medial and lateral collateral ligaments.  The questionable ACL pathology would have produced anterior instability, which all examiners (barring the one equivocal STR finding) confirmed was not present.  There was insufficient evidence for frequent locking (with MRI confirmation of intact menisci) and effusion to support a 20% rating under the 5258 code, and no fracture with non-union or malunion to support a higher rating under the 5252 or 5265 codes.  There was thus insufficient evidence in support of a rating higher than 10% under any applicable code.  

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 of the right knee condition.  

Contended Right Shoulder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the shoulder condition was not unfitting.  The right shoulder condition did not appear to be clinically active at the time of separation, and it was not judged to fail retention standards.  A U2 profile is not routinely associated with unfitting impairment, and does not mandate MEB referral IAW AR 40-501.  There was no performance based evidence from the commander’s statement or STR that the condition significantly interfered with satisfactory duty performance at separation.  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 right shoulder condition and so no additional disability rating is recommended.   

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right shoulder 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.  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 20140510, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR2016001 0891 (PD201402085)

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