RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02165
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Helicopter Repairer, medically separated for “chronic pain, right knee,” with a disability rating of 10%.  

CI CONTENTION:  The CI asserts he has poor quality of life and has had a total knee replacement.  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 - 20050105	VARD - 20050223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Knee	5099-5003	10%	Postoperative Residuals, Multiple Surgeries, Status-Post, Right Knee Anterior Cruciate Ligament Reconstruction	5257-5024	10%	20050215	
			Scars, Residuals, Multiple Right Knee Surgeries
	5257-7805	0%	20050215	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Pain, Right Knee Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right knee surgery in 2000 for right anterior cruciate ligament (ACL) hamstring autograph repair along with a micro-fracture of the lateral femoral condyle.  
In November 2003 he underwent an arthroscopy of the right knee to remove multiple chondral bodies and a cartilage biopsy for a staged autologous chondrocyte procedure.  In March 2004, he underwent an autologous chondrocyte implantation to a lateral femoral condyle lesion and a trochlear lesion.  

During an orthopedic visit in April 2004, 1 month after surgery and 10 months pre-separation, the CI reported continued use of crutches and decreased pain and popping.  On examination the surgical scar was well healed.  Muscle strength was 5/5 and the ROM was 0-140.  At a physical therapy appointment 1 week later, the CI reported decreased pain (rated 1-2/10 at rest and 4/10 at worse).  The examiner documented a ROM of 0-125 degrees.  During a physical therapy appointment in May 2004, 9 months pre-separation, the examiner reported quadriceps (thigh) muscle tone was fair to good.  The ROM was 0-125 degrees.  At an orthopedic appointment in May 2004, 8 months pre-separation, the CI reported 5/10 right knee pain.  On examination the surgical scar was well healed.  There was no effusion, and less than 5 mm of ACL laxity.  The ROM was 0-140 degrees.  Following surgeries further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right knee instability status-post anterior cruciate ligament reconstruction and autologous chondrocyte implantation” for PEB adjudication.  

Right Knee ROM
(Degrees)	Ortho 
~8 Mos. Pre-Sep
(20040526) 	MEB ~5 Mos. Pre-Sep
(20050921) 	VA C&P 
~12 Days Post-Sep
(20050215) 	
Flexion (140 Normal)	140	140	120	
Extension (0 Normal)	0	0	0	
Comment	Painful motion/no effusion/Lachman 1A	Subjective painful motion/subjective instability/tenderness/ trace effusion/
Lachman 1A 	+PM beginning at 90/+TTP 	
§4.71a Rating	10%	10%	10%	

At the MEB NARSUM on 21 September 2004, 5 months pre-separation, the examiner recorded the ability to fully bear weight with persistent subjective pain and instability.  The physical examination noted a well healed surgical incision, with trace effusion, and tenderness of the lateral joint line.  There was evidence of anterior cruciate laxity (less than 5mm) and no evidence of tear.  The ROM was 0-140 degrees.  The examiner diagnosed right knee pain and instability status-post surgery.  

At the VA Compensation and Pension (C&P) examination on 15 February, 2 weeks post-separation, the CI reported almost daily right knee pain 6/10 and flare-ups to 10/10 pain, with weakness and stiffness, once a week.  He reported lack of endurance when walking 100 feet and standing for 10 minutes, the ability to climb one flight of stairs, and periodic use of a knee brace.  The physical examination showed defused swelling with tenderness to the medial, lateral and anterior knee, with guarding evident on movement.  The ROM was 0-120 degrees, with pain.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% coded 5099 5003 (arthritis, degenerative), citing the US Army Physical Disability Agency Policy Guidance Memorandum 13 (Rating Pain).  The VA rated the right knee condition 10%, coded 5257-5024 (knee, other impairment of), citing painful or limited motion of a major joint.  The VA additionally rated the right knee surgical scars at 0% under code 5257-7805 (knee, other impairment of) citing no disability  

There was no limitation of motion which supported a 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).  The examinations proximate to separation did not demonstrate the presence of significant ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (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.  The Board does not recommend disability rating for scars unless their presence imposes a direct functional limitation that renders the CI unfit.  The knee scars did not interfere with wear of military gear and were not painful at the MEB examination.  Any contribution from the scars on ROM limitation was addressed above.  There was insufficient evidence of duty-limiting impairment from the knee scars, thus the Board concluded that the scars condition could not be recommended for additional disability rating.  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 pain, right knee condition.  

BOARD FINDINGS:  
In the matter of the chronic right knee pain and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140514, with attachments
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 AR20160010897 (PD201402165)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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