RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02131
BRANCH OF SERVICE:  Army  	BOARD DATE:  20150505
SEPARATION DATE:  20050731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Military Police) medically separated for left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS), although she was allowed to perform an alternate physical fitness test (APFT).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left knee pain condition, characterized as “chronic left knee pain status post left patellar dislocation,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.   No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left knee pain,” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).   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 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/Naval 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 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:  

IPEB – Dated 20050610	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	0%	Incomplete Tear, Medial Ligament, Left Knee	5260	10%	20050901	
Other x 0 (Not In Scope)	Other x 11	
RATING:  0%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20051213 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Knee Pain.  The narrative summary (NARSUM) notes the CI experienced a traumatic dislocation of the left patella during a training exercise in October 2004.  Notes in the service treatment (STR) record indicated that the CI initially reported left knee pain following a march in April 2004.  The examination and X-rays at that time were normal.  The CI was given anti-inflammatory medication, placed on a temporary profile.  The CI was seen several times from April to October 2004 for left knee pain and noted “popping” and locking and repeat X-rays were normal.  The CI was evaluated in the emergency room for the acute leg injury during training 27 October 2004 and X-rays were again normal.  At a primary care evaluation the next day the CI reported that during training her upper and lower leg went in opposite directions and she felt and heard a `pop’, with immediate pain and swelling of the knee and the knee was noted on exam to be extremely swollen and painful.  The CI was placed on crutches and referred for immediate orthopedic evaluation.  Magnetic resonance imaging 30 October 2004 noted a contusion of the lateral femoral condyle (femur at the outside of the knee) and a partial tear of medial retinaculum (ligament-type tissue on the inner aspect of the patella) and a strain of the medial collateral ligament.  A follow-up orthopedic visit 3 December 2004 the CI reported increased pain with “continued knee dislocations.”  The orthopedic examiner noted decreased swelling and atrophy of the quadriceps muscle (vastus medialis) and the CI was referred for physical therapy.  An orthopedic evaluation 7 January 2005 noted left knee range-of-motion (ROM) of extension-flexion of 0-95 degrees (normal 0–140) with tenderness to palpation (TTP) over the medial retinaculum.  An orthopedic referral dated 11 March 2005 indicated that the CI had plateaued in physical therapy.  According to the NARSUM the CI was not able to return to marching and running and a MEB was initiated.  At the MEB examination 11 May 2005, 3 months before separation, the CI reported left knee pain.  The MEB physical exam noted an angled patella.  There was a mild effusion and positive patellar grind sign.  Knee ROM was 0-110 degrees.  There was no evidence of anterior-posterior or lateral instability 

At the VA Compensation and Pension (C&P) examination 1 September 2005, a month after separation, the CI reported a history of patellar dislocation with spontaneous reduction during a training incident.  She reported continued left knee pain aggravated by walking, kneeling and squatting, without any incapacitating episodes in the past year.  The VA exam noted a normal gait.  The knee was normal in appearance.  There was TTP along the inner aspect of the patella and knee joint with pain limited ROM of 0-90 degrees.  There was mild crepitus with ROM and weakness of the thigh muscles, without evidence of instability or laxity.  The VA C&P General examination 31 August 2005 noted TTP of the knee with a slight limp favoring the left and normal strength, sensation, and reflexes of the extremities.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded 5099-5003 (analogous to degenerative arthritis) an analogous code for patellofemoral pain syndrome.  The VA rated the knee condition 10%, coded 5260 (limited leg flexion).  The Board agreed that the evidence in record supports a 10% rating for the disability due to the knee condition for painful limited motion coded 5003 or for painful motion IAW §4.59 coded 5260.  The Board reviewed to see if a higher evaluation was achieved with any applicable code but there was no evidence of limited leg flexion or extension that met the 10% rating threshold based on ROM alone; impairment of the femur, tibia or fibula with knee disability that could be described as moderate; or, semilunar cartilage related symptoms.  The Board considered if the evidence in record supports recommendation of additional rating of the knee for instability.  At one orthopedic visit the CI reported recurrent knee dislocations, but there was no objective evidence in the STR, at the MEB or C&P exams, or in the 12-month period post separation of instability, laxity, or recurrent patellar dislocation or subluxation following the traumatic patellar dislocation incident in October 2004.  Therefore the Board determined that a rating for knee instability was not appropriate in this case.  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 left knee condition, coded 5099-5003.  

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 left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Knee Pain Condition	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX 
President 
DoD 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 XXXXXXXXXXXXXXXXXXXX, AR20150014204 (PD201402131)

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						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA