RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02466
BRANCH OF SERVICE:  Army	BOARD DATE:  20150515
SEPARATION DATE:  20080107  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (M1 Armored Crewman) medically separated for chronic pain, left knee secondary to patella alta and patellar tendon injury.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “Patellofemoral joint dysfunction” and “deformity of the knee,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain, left knee secondary to patella alta and patellar tendon injury” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  The VA records documented a second period of duty from December 2008 to November 2009; however, the USAPDA confirmed they had no record of a Disability Evaluation System processing subsequent to the CI’s 2008 medical separation.  

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  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 20071129	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee Secondary to Patella Alta & Patellar Tendon Injury	5099-5003	10%	Patella Alta Of The Left Knee (claimed as left knee to
include degenerative left knee changes)	5299-5261	10%	20080325	
Other x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080509 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  

Chronic Pain, Left Knee Secondary to Patella Alta & Patellar Tendon.  The narrative summary and treatment record noted the CI injured his left knee in early 2005.  In October 2005 he had an episode of locking that required joint manipulation to “unlock.”  During deployment to Operation Iraqi Freedom the CI’s knee pain increased and he was evacuated from theater.  Magnetic resonance imaging completed in September 2007 documented a high riding knee cap (patella alta) and bony abnormalities at the patellar tendon insertion (tibial plateau-front of shin, below knee), a bony fragment and extra joint fluid.  There were no meniscal or ligament abnormalities noted.  The CI had a history of Osgood-Schlatter disease as a child (inflammation of the patellar ligament at the tibial tuberosity, characterized by a painful lump just below the knee).  At the MEB exam in September 2007 (4 months prior to medical separation) the CI reported constant left knee pain (6-10/10) aggravated by activities or prolonged sitting.  He was not taking medications.  The MEB physical exam documented the left knee had warmth around the patella ligament and a tender and warm knee with a prominence (deformity) of the area of patellar tendon insertion.  There was tenderness, painful motion, and a high riding patella which tracked normally (no subluxation).  “The motion of the knee was restricted, particularly to flexion.  Possible 15 to 20-degree loss of terminal flexion is noted” [equates to 120-125 degrees of flexion of normal 140 degrees].  There was no knee instability or muscle weakness.  The conclusion was of an avulsion injury (ripping) of the patellar ligament in the presence of Osgood-Schlatter disease that resulted in a high riding knee cap and permanent inflammation of the patellofemoral joint.  

At the VA Compensation and Pension exam performed in March 2008 (2 months after medical separation) the CI reported a similar history and complained of a “locking” sensation with associated “popping” sensation as well as decreased motion of the knee.  Pain increased with activities, he had flare-ups, and took Tylenol as needed for pain.  The CI used a left knee brace.  Exam documented a tender knee with pain-limited flexion to 120 degrees (140 normal) and 5 degrees of extension (normal 0).  Strength was 4/5 on flexion and extension.  There was no instability and meniscal testing was negative.  

Following medical separation in January 2008, the CI underwent left knee surgery in June 2008 to remove the bony mass next to the patellar tendon.  In July 2007, an orthopedic evaluation indicated the CI denied any pain, swelling, catching or clicking of his knee.  The assessment was that the CI was fully recovered with no pain or limitation of motion.  VA records indicate the CI returned to military service from 23 December 2008 to 10 November 2009.  There were two emergency room treatment notes in May and June 2009 for left knee injury, with the June note indicating use of a knee brace.  VA left knee rating remained at 10% until July 2012 when it was increased to 30% (based on limited flexion from exams in 2012).  

The Board directed its attention to its rating recommendation based on the above evidence.  All exams proximate to the CI’s January 2008 medical separation warranted a 10% rating for pain-limited motion.  There was no instability for dual rating and neither flexion nor extension were limited to the compensable levels for rating under the specific knee codes absent application of VASRD §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board agrees that concluded that a disability rating of 10% for the left knee condition was appropriately recommended in this case at the 2008 date of separation.  

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 knee condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left knee condition 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.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination in 2008.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 2014506, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
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, AR20150014425 (PD201402466)

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