RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02801
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Patriot Fire Control, medically separated for “right knee pain related to anterior cruciate ligament (ACL) tear, chondromalacia, and lateral meniscal tear” with a disability rating of 10%.  

CI CONTENTION:  The CI contends he was impacted by his disabilities and should have received a higher rating.  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 - 20080626	VARD - 20081016	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain, related to Anterior Cruciate Ligament (ACL) Tear, Chondromalacia, and Lateral Meniscal Tear	5299-5257	10%	S/P Knee Anterior Cruciate Ligament Tear with S/P Medial Meniscal Tear	5257	10%	20080718	
			Degenerative Changes and Chondromalacia, Right Knee	5010-5260	10%		
			Scar; S/P Arthroscopic and Reconstructive Surgery, Right Knee	7804	10%		
Cystic Acne	Not Unfitting	Cystic Acne	7828	0%		
GERD	Not Unfitting	Gastroesophageal Reflux Disease	7399-7346	0%		
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain condition began in July 2005 after tearing his anterior cruciate ligament (ACL) and medial collateral ligament (MCL).  No specific injury or trauma was noted that precipitated his knee injury.  He continued to have knee swelling and recurrent knee pain.  In October 2006, he underwent a right knee arthroscopic lysis of adhesions which revealed chondromalacia in both condyles.  In July 2007, the CI had a follow-on arthroscopy of the knee, chondroplasty of the patella, an excision of the medial synovial plica and a repeat debridement of the ACL.  An MRI performed in 2007 and 2008 suggested a partial tear of the ACL graft.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded the four diagnoses of “chronic anterior cruciate ligament tear; chondromalacia patella; lateral meniscal tear; and chronic pain syndrome” for PEB adjudication.  

The 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.  

Right Knee ROM
(Degrees)	MEB/PT ~1 Mo. Pre-Sep	VA C&P ~0 Mo. Post-Sep	
Flexion (140 Normal)	130,130,130	100	
Extension (0 Normal)	10,10,10	0	
Comment	Painful motion; tenderness; 2-A Lachman	Painful motion; +Lachman’s; -McMurray’s	
§4.71a Rating	PEB 10%	VA 20%	
5257	10%	10%	
5003 (equivalent)	10%	10%	

A radiologic examination in June 2008, 1 month before separation, noted no significant joint effusion, no significant degenerative changes, normal pin placement and no evidence of maltracking.  During the MEB examination (recorded on DD Forms 2807 and 2808) dated 21 May 2008, 2 months prior to separation, the CI reported right knee swelling with locking and that the right knee did not straighten.  He reported a history of a torn ACL, torn meniscus, right ACL reconstruction and 3 arthroscopic procedures (retained screw) with required use of a knee brace.  The physical exam showed right patellar tendon tenderness to palpation (TTP) with laxity and right quadriceps atrophy.  The CI also lacked full extension of the right knee.  The MEB NARSUM, 6 June 2008, 1 month prior to separation, the CI reported right knee pain and instability of the right knee.  The MEB physical examination noted well-healed scars in both the anterior and medial regions.  There was TTP without effusion.  “Please defer the range of motion to the Physical Therapy measurements [charted above], but roughly in the clinic passively he is 15-130 degrees … He has a 2-A Lachman, with a firm endpoint, but loose compared to the contralateral side.”   There was difficulty performing a McMurray’s test due to severe pain grossly about the knee.  Motor strength and sensations were normal.  

At the VA Compensation and Pension (C&P) examination in 18 July 2008, performed at the time of separation, the CI reported that while running he heard a snapping and popping sound from his right knee.  A subsequent X-ray revealed a torn ACL and he obtained corrective surgery.  The physical exam showed the CI could walk without support of a cane or wheelchair.  The CI did not have an antalgic gait.  There was mild laxity of the right knee with painful motion as charted above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5299-5257 code (knee, other impairment of:  recurrent subluxation or lateral instability), citing Lachman’s with stable end point, tenderness and strength equal to the contralateral side with a ROM of 10-130 degrees.  The VA assigned a 10% rating using the 5257 code based on the VA C&P examination at the time of separation, citing right knee meniscal tear with mild instability and positive Lachman’s test of the right knee.  The VA assigned a 10% rating using code 5010-5260 (arthritis, due to trauma - leg limitation of flexion of) for chondromalacia of the right knee.  The VA also assigned a 10% rating using the 7804 code (scars, unstable or painful) citing a 7 centimeter scar, mild keloid and tenderness that was painful on examination.  The Board deliberated if there were sufficient evidence of knee laxity/instability and painful motion or non-instability symptoms related to the CI’s meniscal surgery for dual rating of the knee as awarded by the VA.  There was evidence of slight knee instability on all exams supporting a 10% rating under 5257 as adjudicated by the PEB and VA.  Although the ratable limitation of extension (code 5261) documented by the MEB was resolved by the time of the VA examination, all examinations documented evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Although the VASRD criteria for rating scars under 7802 and 7804 could reasonably be applied in this case, the Board does not recommend disability rating for scars unless their presence imposes a direct functional limitation that renders the CI unfit.  The knee scars did not interfere with wear of military gear.  Any contribution from the scars on ROM limitation was addressed above.  There was insufficient evidence of duty-limiting impairment from the right knee scars, thus the Board concluded that the scars condition could not be recommended for additional disability rating.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separation rating of 10% for knee instability, coded 5299-5257, and 10% for painful motion, coded 5010-5260, for a combined rating of 20% for the right knee condition.  

Contended PEB Conditions.  Cystic Acne, GERD, and Migraine Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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:  In the matter of the right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5257 and 10% coded 5010-5260; both IAW VASRD §4.71a.  In the matter of the contended GERD; migraine headaches and cystic acne conditions, the Board unanimously or majority recommends no change from the PEB determinations as not unfitting.  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	
Right Knee Pain related to ACL Tear, Chondromalacia, and Lateral Meniscal Tear	5299-5257	10%	
	5010-5260	10%	
COMBINED	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160010995 (PD201402801)

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