RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03074
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060111

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Abrams Tank System Maintainer) medically separated “chronic left knee pain,” rated at 0%.

CI CONTENTION:  “Please consider all options” His 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 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:  

IPEB – Dated 20051212	VA* - (~12 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Left Knee Strain	5257	10%	20061228	
			S/P Gun Shot Wound, Left Thigh	5313	0%	20061228	
Other x 0 (Not In Scope)	Other x 6 	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070813 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Left Knee Pain Condition.  The CI initially presented in May 2002 with left knee pain which was attributed to overuse.  He was treated conservatively with physical therapy, activity modification, and anti-inflammatory medications.  A bone scan performed in August 2002 was negative.  The CI was diagnosed with patellofemoral pain syndrome (PFPS) in October 2002.  He continued to report intermittent knee pain with continued conservative management.  In January 2005, the CI sustained a gunshot wound (GSW) to the left thigh.  A treatment note dated 30 June 2005 documented normal healing although bullet fragments were still imbedded in the anterior thigh.  The examiner also noted reports of pain just below the knee cap to right above the GSW entry scar.  The pain was rated 7/10 which increased to 10/10 an exacerbation.  On physical examination there was full active knee range of motion; a patellar float (the knee cap moves out of it normal location with motion); and mild tenderness to palpation over the GSW scar, hamstring tendon, and distal patella.  The examiner listed diagnoses of possible PFPS, hamstring tendonitis, and chronic pain from foreign body in thigh.  The narrative summary (NARSUM) examiner noted reports of intermittent and ongoing pain about the patella of his left knee with occasional giving out and swelling. The pain in the left lower extremity from PFPS and at the site of the GSW resulted in difficulty running any amount of distance and walking, squatting or kneeling for any length of time.  On physical examination there was full active left knee range of motion, normal muscle strength, a positive patellar grind (grating or grinding sensation at the site of the patella with knee flexion and extension), moderate patellar apprehension ( a test for patellar instability), and a mildly tender, well healed entrance wound.  The examiner rendered diagnoses of left knee pain consistent with PFPS and myofibrosis (muscle scarring) of the left thigh.  

At the VA Compensation and Pension (C&P) examination performed 12 months after separation, the CI reported constant pain in the left thigh and knee.  The thigh pain was described as 7/10 sharp, aching pain with activity.  The left knee pain was described as localized to the knee, constant, and rated 8/10 with physical activity.  The left thigh and knee pain were relieved by rest and anti-inflammatory medication.  The physical examination demonstrated full painful left knee range-of-motion, a slow gait with occasional limping, and normal motor strength.  The examiner noted that there was no fatigue, weakness, lack of endurance or incoordination of the left lower extremity.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left knee PFPS and left thigh myofibrosis pain as a single unfitting condition at 0% with likely application of USAPDA pain policy. IAW DoDI 6040.44 if the PEB combined adjudication is not VASRD rating compliant, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. In this case, both the left knee PFPS and left thigh myofibrosis pain were considered to fail retention standards and implicated by the NARSUM and in the commander’s statement.  The Board noted that the left knee pain predated the anterior thigh pain.  The Board further noted that the NARSUM examiner opined that the left thigh pain contributed to the left lower extremity impairment.  Members agreed that the left knee PFPS could be reasonably justified as separately unfitting and the left thigh pain contributed to the unfitting knee condition, but could not be reasonable justified as separately unfitting.  The Board then considered the rating recommendation for the CI’s left knee.  The Board noted that that the left knee examination demonstrated full active range of motion; therefore there was no compensable limitation of motion.  Multiple service treatment notes and VA records documented reports of pain with use and objective findings of crepitus and a patellar tracking pathology which met criteria for application of VASRD 4.40, functional loss for a minimum compensable rating of 10%.  There was no avenue to a higher rating for the left knee PFPS.  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 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating left knee PFPS and left thigh myofibrosis pain was operant in this case and the conditions were adjudicated independently of that policy by this Board.  In the matter of the left knee PFPS condition, the Board unanimously agreed that it was separately unfitting and recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left thigh myofibrosis condition, the Board unanimously agreed that it was not separately unfitting and therefore, cannot be recommended for additional disability rating.  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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left knee pain 	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140627, 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 XXXXXXXXXXXXXXXXXXXX, AR20160005018 (PD201403074)

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