RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2014-02702
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080825

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling National Guard, E4, Infantryman, medically separated for “left knee pain with some laxity …” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention in their application.  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 - 20080710	VARD - 20080716	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain With Some Laxity …	5257	10%	Laxity, Left Knee	5257	10%	20071018	
			Traumatic Arthritis, Left Knee	5010-5260	10%	20071018	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in November 2001, prior to enlisting in the National Guard, undergoing an anterior cruciate ligament (ACL) reconstruction that month.  After enlisting, he reinjured the knee in October 2005 during a road march.  Diagnostic imaging (MRI) in June 2006, 26 months prior to separation, noted normal appearing ACL graft with a tear of the meniscus associated with degenerative changes and chondromalacia with small joint effusion of the left knee.  

At a VA Compensation and Pension (C&P) examination in October 2007, performed 10 months before separation, the CI reported left knee pain with weakness, stiffness, swelling, and instability, but no locking, heat or redness.  Physical exam showed swelling, crepitus, tenderness, and laxity.  There was painful limited motion as charted below, but no further decrease in range of motion (ROM) or joint function following repetitive use.  

The NARSUM, written in June 2008, 2 months prior to separation, indicated the CI complained of left knee pain and swelling.  Physical exam showed no soft tissue swelling, effusion, erythema, or deformity.  There was tenderness to palpation, a positive grind test, a grade 1 Lachman’s, a negative Drawer’s test, and no varus or valgus laxity.  Strength was 5/5.  The formal physical therapy ROM note was incomplete, but active ROM was less than passive ROM and is summarized below.  Orthopedic consult in September 2008, a month after separation, the CI reported pain, intermittent swelling, and instability with a feeling of giving way when climbing.  Exam stated “obvious instability of the left knee with positive anterior drawer sign.”  

At a VA C&P examination in April 2009, 8 months after separation, physical exam indicated pain on motion (with limitation summarized below), crepitus, effusion, instability (ACL 7mm), guarding, and a small joint effusion.  MRI from September 2008 documented intact ACL graft meniscus damage “in part related to partial meniscectomy,” mild tricompartmental degenerative changes, chondromalacia and a small joint effusion.  The 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)	VA C&P
~10 Mo. Pre-Sep	NARSUM / PT Exam
~3 Mo. Pre-Sep	VA C&P
~8 Mo. Post-Sep	
Flexion (140 Normal)	135	130	120	
Extension (0 Normal)	0	0	0	
Comment	See text above (laxity)	See text above (Lachman 1)	See text above (laxity)	
§4.71a Rating	VA 20%	20% (PEB 10%)	No change to initial 20% rating	
5003	10%	10%	10%	
5257	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under code 5257 (knee, other impairment of: recurrent subluxation or lateral instability), citing some laxity, “ROM normal (0-130 degrees)” and no pain noted on ROM study.  The VA also assigned a 10% rating using code 5257 based on the VA C&P examinations 10 months before and 8 months after separation, citing slight lateral instability of the knee; and, the VA also assigned a 10% rating using the 5010-5260 code (arthritis, due to trauma, substantiated by X-ray findings and leg, limitation of flexion of) using the same VA exams and citing traumatic arthritis with painful and limited motion.  

Board members agreed that with regards to rating under code 5257 (instability) that the objective examination findings by all examiners of instability were no more than mild.  The Board adjudged that this evidence most accurately described “slight” instability (10%) under the 5257 code.  The Board then considered if dual coding, as assigned by the VA, was appropriate.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  Although the PEB indicated normal ROM, there was limitation below 140 degrees of flexion on all exams.  Additionally the CI had meniscal pathology and symptoms other than instability that would warrant a 10% rating analogous to code 5259 (which includes painful motion).  The Board considered the VA exams and the treatment record and agreed that there was sufficient evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  It was agreed that frequent locking due to dislocated semilunar cartilage was not present, and therefore a 20% rating was not justified under the 5258 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a separation rating of 10% for (painful motion/meniscal symptoms), coded 5259-5003, and 10% for knee instability, coded 5257, for a combined rating of 20% for the left knee condition.  

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends a combined disability rating of 20%, coded 5257 at 10% and 5259-5003 at 10% IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain With Some Laxity	5257	10%	
	5259-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160007636,  

Dear 

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability. I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

 
Enclosure