RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02134
BRANCH OF SERVICE:  Army	BOARD DATE:  20150129
SEPARATION DATE:  20011011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-1 (Basic Trainee) medically separated for chronic pain in the left knee.  The left knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but was authorized to perform an alternate physical event to satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “left anterior cruciate ligament (ACL) tear” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic pain, left knee” as unfitting, rated 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  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 Veterans Affairs Schedule for Rating Disabilities (VASRD) / 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 IPEB – Dated 20010810	VA - (3 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee	5099-5003	10%	Left Knee Arthritic Changes	5260	10%	20010716	
			Left Knee Positive Drawer Test	5257	10%	20010716	
			Surgical Scars, Left Knee	7804	10%	20010716	
Other x 0 (Not In Scope)	Other x 2	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20010907 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY: 

Left Knee Condition.  The narrative summary (NARSUM) notes the CI sustained an injury to his left knee in July 2000.  A magnetic resonance imaging of the knee on 24 August 2000, revealed a tear of the ACL and two tears of the cartilage on the inner knee area (medical meniscus).  In February 2001, the CI underwent repair of the ACL with a tissue graft and debridement of the areas of meniscal injury.  Immediately before the procedure, examination under anesthesia revealed no lateral instability and moderate anterior instability of the knee (2B Lachman test).  At the completion of the procedure, re-examination under anesthesia revealed no knee instability.  On a physical therapy evaluation on 22 March 2001, range-of-motion (ROM) of the knee was flexion 110 degrees and extension had +5 degrees of hyperextension. (Normal: 140 and 0 degrees).  On an orthopedic exam on 7 May 2001, surgical incisions were well healed and the knee had no lateral instability (varus/valgus) but mild “laxity” at the ACL repair site (1A Lachman test).  At the MEB/NARSUM evaluation on 25 June 2001, 4 months prior to separation, the CI reported a continued inability to walk or run without knee pain.  The MEB physical exam, performed by an orthopedic surgeon, noted some swelling (effusion) of the left knee.  Surgical wounds were well healed.  Motor strength and sensation in the lower legs was normal.  No lateral (varus/valgus) instability was present.  Mild anterior laxity was again noted (1A Lachman test).  ROM results are in the chart below.  On the DD Form 2808 Physical examination for the MEB, performed on 6 August 2001, 2 months prior to separation, the anterior laxity of the knee was described as “minimal.”  At the VA Compensation and Pension (C&P) exam performed 3 months prior to separation, the CI reported pain, instability and locking and “clicking” of the left knee.  On physical examination, the CI had a normal gait.  The small surgical scars were described as “tender” to palpation without inflammation, instability, tissue loss or functional impairment.  Evidence of ACL instability was reported (+ Drawer sign) with slight swelling of the knee.  No locking, “popping” or crepitus was reported on motion of the knee.  ROM findings are summarized in the chart below.  X ray of the knee revealed arthritic changes with a bony fragment within the joint. 

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

Left Knee ROM
(Degrees)	
PT ~7 Mo. Pre-Sep
	
MEB ~4 Mo. Pre-Sep
	
VA C&P ~3 Mo. Pre-Sep
	
Flexion (140 Normal)	135	130	120 with pain	
Extension (0 Normal)	+5 (hyper extensible)	0	0	
Comment	One month post surgery.  Brace given for hyper extensibility	No lateral instability. Some laxity (1A Lachman). Mild effusion	Gait normal. + Drawer sign. Mild effusion. No ‘popping’ or locking on motion.	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition at 10% using the Army pain policy  The VA dual rated the knee condition at 10%, code 5260 (limitation of flexion) citing forward flexion limited to 45 degrees and at 10%, code 5257 (Instability), citing a “positive drawer test.”  Under code 5260, a rating of 0% rating is given for limitation of flexion of the knee to 60 degrees.  A 10% rating requires limitation of flexion to 45 degrees.  Under code 5257 (instability), a 10% rating requires the condition to be “slight.”  A higher rating of 20% requires the condition to be “moderate.”  The VA added a third rating of 10%, code 7804 (scars) for painful surgical scars.  The Board agreed that the evidence in record did not support a rating for the knee condition for limitation of ROM, codes 5261 or 5262.  Members agreed that the knee condition met the criteria for a 10% rating IAW §4.59 and §4.40 for painful motion.  The Board undertook a rating under code 5257(Impairment/instability).  The Board noted the report on the C&P exam of instability, but agreed this was internally inconsistent with the reported normal gait.  The Board consensus was that the evidence in record supported the knee to have some mild anterior laxity but no frank instability after surgery and, thus, did not meet the criteria for rating under code 5257.  The Board noted the subjective report of the CI of locking of his knee and the findings on X-ray of a free bony fragment within the knee joint and considered a rating under code 5258 (Cartilage, dislocated).  The Board found no objective evidence in the record of this condition and was, thus unable to ascertain whether this met the criteria for “frequent episodes” as required by code 5258 (Cartilage, dislocated/frequent episodes) for rating.  The Board considered a rating under code 5262, (Tibia impairment/ knee disability).  Under this code a rating of 10% requires the condition to be “slight.”  A higher rating of 20% requires the condition to be “moderate”.  A higher rating of 30% requires the condition to be “marked.”  The Board agreed that the left knee condition met the requirement for a 10% disability, but no higher, given the normal gait and minimal findings on examinations proximate to separation.  The Board considered a rating under 7804 (Scars) for surgical scars, but was unable to do so as scars were small, stable, well-healed and of no functional significance.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the left knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left knee condition, the Board unanimously recommends no change in the PEB adjudication.  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 20140423, 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 XXXXXXXXXXXXXXX, AR20150010559 (PD201402134)

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		    XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA