RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02523
BRANCH OF SERVICE:  Army	BOARD DATE:  20150616
SEPARATION DATE:  20041221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Personnel Administrative Specialist) medically separated for right knee pain.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic right knee pain status post two surgeries” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated the right knee as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The condition to my right knee is more severe than the 0 percent awarded by the military.”

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:

IPEB – Dated 20041101	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain Status Post Two Surgeries	5099-5003	0%	Right Anterior Cruciate Ligament (ACL) Tear, Status Post Surgery	5299-5260	0%	STR	
Other x 0 (Not In Scope)	Other x 0	
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20060315 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Knee Condition.  The narrative summary notes the CI injured his right knee on 6 July 2003 when he jumped from a height and the knee buckled to the side.  Initial and repeat knee X-rays demonstrated a knee effusion, without any fracture.  The CI was evaluated by an orthopedic specialist in December 2003 and the exam noted “significant hyperextension recurvatum” (also known as genu recurvatum or knee hyperextension - may be due to familial joint laxity or traumatically acquired) and anterior instability and lateral laxity (mild laxity was noted on the uninvolved left knee also).  Magnetic resonance imaging of the knee showed ACL and posterior corner injury (ligaments and tendons that stabilize the posterior and lateral knee) and lateral meniscus tear.  The surgeon recommended a two stage surgical repair of the knee.  The initial surgery was performed on 26 January 2004 to repair the posterior knee ligaments/tendons and the second surgery was performed on 26 April 2004 for ACL repair and debridement of the lateral meniscal tear.  The surgeon noted that the CI had 10 to 15 degrees of knee hyperextension bilaterally prior to the second surgery.  Notes indicated that the CI was not fully compliant with wearing a knee brace during his rehabilitation and later evaluations noted mild residual joint laxity, with mildly positive anterior instability testing and knee extension of 5 degrees hyperextension (normal 0).  The CI had reported little to no knee pain at multiple treatment visits, but at a physical therapy (PT) visit on 13 August 2004 he reported recent increased knee pain with activities such as walking, standing or sitting.  At a PT visit on 14 October 2004 the CI reported no current pain, but uncomfortable `popping’ in his knee when putting on his knee brace.

At the MEB examination, 1 October 2004, 3 months prior to separation, the CI reported chronic right knee pain with use of anti-inflammatory medication three times per day and pain medication once daily.  The MEB physical exam noted a normal gait.  There was crepitus of the right knee with extension, without tenderness to palpation or effusion.  Knee range-of-motion (ROM) was 5 degrees of hyperextension and 140 degrees of flexion (normal 140), without pain.  The uninvolved left knee ROM was reported as 20 degrees of hyperextension.  The CI failed to report to the scheduled VA Compensation and Pension (C&P) examination 4 January 2006.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition at 0%, coded 5099-5003 (analogous to degenerative arthritis) and cited the USAPDA pain policy.  The VA rated it at 0%, coded 5299-5260 (analogous to limited leg flexion), noting the CI did not attend the scheduled C&P examination.  The Board considered the evidence in the STR which indicated following the second surgery the CI continued to report knee pain with activities and orthopedic evaluation noted residual anterior joint laxity.  Members first considered rating the knee for instability coded as 5257 (other knee injury).  Members deliberated whether the evidence in record of hyperextension and mild laxity of the uninvolved left knee had any implications for its rating recommendation for the right knee.  Following discussion the Board concluded that the noted general joint laxity was a moot issue because if the noted anterior laxity was symptomatic on the right following the injury and surgeries, the Board considered it eligible for rating consideration.  The Board noted that the rating criteria of 5257 are subjective with 10% for “mild” and 20% for “moderate” lateral laxity.  There was no evidence of the knee buckling or “giving way,” patellar subluxation, or the CI losing balance or falling down.  Although the CI was recommended to wear a knee brace, the evidence indicated he was not always compliant in doing so and at the MEB exam a normal gait was noted.  For these reasons the Board’s opinion was that the disability effects of the residual joint laxity were best described as mild and the knee condition met a 10% rating coded as 5257.  The Board also considered that the laxity of the knee, with hyperextension of the knee noted in record, could be rated alternatively coded as 5263 (genu recurvatum) which provides a sole 10% rating.  A 10% rating was also achieved for limited motion coded as either 5299-5260 (analogous to limited leg flexion) with consideration of §4.40 (Functional loss), which states that a part that becomes painful on use “must be regarded as seriously disabled,” or coded as 5259 for symptomatic semilunar cartilage removal, which provides a sole 10% rating.  The Board reviewed to see if a higher evaluation was supported by any other applicable code but there was no evidence of limited leg flexion or extension based on ROM alone, frequent “locking” and effusion, tibia, fibula, or femur impairment with “moderate” knee disability, or ankylosis to support a higher rating.  The Board finally deliberated the application of dual ratings, based on separate ratings for instability and limitation of motion.  The Board majority determined that providing a 10% rating for limited motion coded as 5259 was warranted in this case, in addition to a 10% rating for instability.  Members agreed that coding the instability as 5257 rather than as 5263, was more appropriate for the post-operative anterior laxity noted, because the hyperextension was present bilaterally and was actually reduced on the right after the surgical repair compared to the uninjured left knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a rating of 10% for the knee instability, coded 5257 and 10% for limited motion, coded 5259, for combined 20% rating of the knee condition.

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 knee condition, the Board majority recommends a dual disability rating of the knee as follows: 10%, coded 5259 and 10%, coded 5257 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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Right Knee Pain and Instability Condition	5259	10%	
	5257	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140531, 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 XXXXXXXXXXXXXXXXXX, AR20160002811 (PD201402523)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA