RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02661
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060223

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV1/E-1 (45B00/Small Arms/Artillery Repairer) medically separated for chronic left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left knee pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic left knee pain and patellar subluxation with onset during WTC in Oct 05” as unfitting, rated 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 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 20060215	VA* -  based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain and Patellar Subluxation with Onset During WTC in Oct 05 	5099-5003	0%	Chondromalacia Patella with History of Instability, Left Knee	5271-5024	10%	STR	
Other x 0 (Not In Scope)	Other x 1	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20060310 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Left Knee Pain and Patellar Subluxation. The earliest note in the service treatment record (STR) dated 7 October 2005 indicated the CI had a cellulitis/abscess distal to the patella (knee cap) marked with decreased range-of-motion (ROM) due to pain.  She was treated with an antibiotic and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug).  One week later she presented to the Emergency Department with left knee pain after having felt her left patella going out and back again while running.  Apparently, this was the third occurrence of patellar subluxation.  X-rays demonstrated minimal degenerative change with medial compartment and minimal joint space loss and minimal lateral femoral condylar (a projection of the femur) spurring.  A thick effusion was present in the suprapatellar bursa (fluid filled sac) and sclerosis (thickening) was present in the inferior aspect of the patella.  On 14 October 2005, the CI indicated pain persisted at the site of the abscess, which had cleared, and treatment was with prednisone.  Follow-up revealed swelling from the knee to the ankle suggestive of a knee strain/edema.  Orthopedic evaluation on 19 October 2005 found a moderate effusion with painful patellar ballottement (a test indicating increased fluid around the joint) of the left knee.  The diagnosis of left patellar instability was made and a knee immobilizer and physical therapy were ordered.  By January 2006, in spite of physical therapy, the CI failed to rehabilitate, was diagnosed with chondromalacia patellae (inflammation of the underside of the knee cap and softening of the cartilage) based on examinations of the left knee that were marked by slight swelling, tenderness to palpation below the patella, and several small pink spots on the lower leg as well as a full ROM that hurt to bend.

The MEB narrative summary (NARSUM) dated 20 January 2006 noted the CI came into the WTC (Warrior Transition Command) program for training upon return to the military and began having left knee pain while running.  Her patella felt like it shifted back and forth twice without pain.  One month into training the knee shifted a third time and she had significant pain with a moderate amount of swelling and was unable to run thereafter.  Anti-inflammatory medications, activity limiting profiles, physical therapy, a knee immobilizer, and use of a cane failed to alleviate her problem and she was unable to get back into training.  Examination revealed significant left knee pain with a patellar grind test (to detect the presence of a patellofemoral joint disorder) and some crepitus (grinding sensation) although she had significant hypersensitivity. No effusion was present. The ROM with a goniometer was -2 to 130 degrees with apparent discomfort.  There was no instability to AP (anterior/posterior drawer tests) or varus/varus stress.  She was able to straight leg raise against resistance, but it was painful and she had a mild antalgic gait.  X-rays of the left knee were normal.  Because of the functional limitations and pain associated with her condition, she was unable to complete the very intense and physically demanding training.

The commander’s statement dated 23 January 2006 indicated the CI was diagnosed with a left knee injury that would limit participation in any part of training and was unable to perform any assigned duties.  The CI noted on the Report of Medical History (DD Form 2807-1) dated 23 January 2006 a dislocated knee cap, knee pain, and a [limited] ROM of the knee.  The examiner noted on the Report of Medical Examination (DD Form 2808) dated 26 January 2006 left knee pain with flexion, extension and squatting.  A permanent L3 physical profile was issued on 3 February 2006 for left knee pain with military limitations of carrying and firing a weapon, constructing an individual fighting position, and performing rushes under direct and indirect fire as well as physical fitness testing including of running, walking, and biking.

No Compensation and Pension (C&P) examination was performed proximate to separation.  The VA Rating Decision (VARD) dated 10 March 2006 was based on the STR, which noted recurrent pain, swelling, and patellar instability of the left knee with occasional giving out, but no locking.  X-rays were reported to show spurring and the record did not show any additional functional loss due to pain caused by flare-ups or with repetitive use.
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 (degenerative arthritis) for chronic left knee pain and patellar subluxation.  The VA assigned a 10% rating using code 5271-5024 (limitation of motion of the ankle/tenosynovitis) for chondromalacia patellae with a history of instability of the left knee based on painful motion. The Board sought a route to a higher rating and noted that the ROMs proximate to the time of separation were noncompensable. However, a 10% rating using of analogous code 5099-5003 is appropriate since there was documented swelling of the knee, a mild antalgic gait, a positive patellar grind test, and a straight leg raise against resistance was painful.  The Board also considered use of code 5257 related to recurrent subluxation.  The STR identified one episode of patellar subluxation and by history there were at least two other episodes.  However, the NARSUM examination failed to specifically address patellar tests necessary to determine patellar subluxation, but noted no evidence of either anterior/posterior instability or varus/valgus instability and the STR was otherwise silent on whether the patellar subluxation occurred after wearing a knee immobilizer or after physical therapy.  Therefore, it would be speculative to suggest whether patellar subluxation was ratable as slight (10%), moderate (20%) or severe (30%) at the time of separation in the absence of credible medical evidence in the STR as well as being inconsistent with VASRD §4.2 (Interpretation of examination reports), VASRD §4.3 (Resolution of reasonable doubt) and VASRD §4.6 (Evaluation of evidence).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic left knee pain 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chronic left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Knee 	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140502, 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, AR20160003705 (PD201402661)

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 10% 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