RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02275
BRANCH OF SERVICE:  Army	BOARD DATE:  20150519
SEPARATION DATE:  20080325

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Military Police) medically separated for left knee pain.  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 fitness test (per PROFILE).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “grade 4 chondromalacia of the left trochlea” and “grade I posterior cruciate ligament (PCL) injury,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (hypertension and nephrosclerosis with hypertension benign) as medically acceptable conditions for PEB adjudication.  The Informal PEB (IPEB) adjudicated “chronic knee pain due to Grade 4 chondromalacia of the left trochlea and Grade I PCL injury” as unfitting, rated 10%, citing application of the Department of Defense Instruction (DoDI) 1332.39.  The hypertension and nephrosclerosis conditions were determined to be not unfitting.  The CI initially appealed the IPEB decision demanding a Formal PEB, but later changed his decision agreeing with the IPEB adjudication.  The US Army Physical Disability Agency (USAPDA) later issued an IPEB re-print and an administrative correction (to conform with the National Defense Authorization Act of 2008).  Neither of the two documents changed the IPEB’s unfitting condition or rating.  The CI was medically separated.

CI CONTENTION:  “High Blood Pressure, P.T.S.D., Lower back Problems, Left Knee Problems, Heart 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) 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:

USAPDA Admin Corr IPEB – Dated 20080417	VA*-(6 Days Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain…	5257	10%	Chondromalacia…, Left Knee	7804-5260	10%	20080331	
Hypertension	Not Unfitting	Hypertension/Nephrosclerosis	7507-7101	20%	20080331	
Nephrosclerosis with Hypertension Benign	Not Unfitting					
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 6	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20080428 (most proximate to date of separation).

ANALYSIS SUMMARY:  

Left Knee Condition.  The CI suffered a left knee injury when he slipped and fell in May 2006.  He was evaluated in the emergency room where a plain film X-ray revealed a small effusion in the left knee.  He continued to have pain and in July 2006, an orthopedic surgeon requested magnetic resonance imaging study revealed a torn PCL tear among other less significant findings.  Non-operative treatment with physical therapy, non-steroidal anti-inflammatory drugs and duty restriction was instituted.  The CI’s left knee symptoms continued and he underwent arthroscopic procedure in January 2007.  That procedure revealed a Grade I PCL injury.  It was intact but with a small amount of laxity, and no repair was performed.  There was also significant, Grade IV, chondromalacia of the trochlear portion of the left knee, Grade I chondromalacia of other areas of the knee and “significant synovitis” (swollen synovial membrane) in the anterior knee, that was trimmed down.  There was no meniscal abnormalities noted.  Over the next 8 months, the CI’s left knee pain and duty restriction continued and he was entered into the disability evaluation system.  The narrative summary completed 8 months prior to separation noted that the CI’s main complaint had been left knee pain as opposed to instability.  He attended physical therapy and had regained his motion and his strength, but did have some residual anterior knee pain with prolonged standing, walking, kneeling, and squatting activities.  He was unable to run.  At the VA Compensation and Pension exam performed 6 days after separation, the CI reported chronic recurrent left knee pain with activity such as prolonged standing, walking, running, and with climbing and descending stairs.  No treatment was required for this condition.

The goniometric range-of-motion (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)	DD 2808 ~9 Mo. Pre-Sep	NARSUM ~8 Mo. Pre-Sep	VA C&P 6 Days Post-Sep	
Flexion (140 Normal)	“FROM”	130	105	
Extension (0 Normal)		0	0	
Comment	Pos. crepitus; No effusion or tenderness to palpation; Normal strength & reflexes	Stable knee; No effusion; Pos. patellar grind	Normal gait; No effusion or instability; Pos. painful motion	
§4.71a Rating	10%*	10%* (PEB 10%)	10%* (VA 10%)	
*IAW VASRD 4.59, Painful motion

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left knee condition by applying VASRD code 5257 (other impairment of the knee) and rated it 10% citing application of DoDI 1332.39.  The VA applied a combination code of 7804 (painful superficial scars) with 5260 (limitation of leg flexion) and rated it 10% citing, “…because there is evidence of functional loss due to pain….”  The evidence present for review supports that there was no left knee instability, meniscal injury, or compensable decrease in knee ROM as required for application of any knee specific VASRD code.  However, there is ample evidence of painful motion IAW VASRD §4.59 (painful motion) and §4.40 (functional loss) as required for application of code 5003 (degenerative arthritis) and a 10% rating based on §4.59 and §4.40.  There was no evidence of incapacitation due to the left knee pain that would support a 20% rating under 5003.  There is no appropriate VASRD based coding/rating scheme that would result in a rating greater than 10%.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), Board members agreed that the disability rating of 10% for the left knee condition was appropriately recommended in this case.

Contended Hypertension and Nephrosclerosis with Hypertension Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension and nephrosclerosis with hypertension were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The hypertension and nephrosclerosis with hypertension conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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 any of the contended conditions and so no additional disability ratings are 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.  As discussed above, PEB reliance on DoDI 1332.39 for rating the left knee condition was operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the 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 hypertension and nephrosclerosis with hypertension conditions, the Board unanimously recommends no change from the PEB determinations 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 20140516, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20150018399 (PD201402275)

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