RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03186
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Aircraft Power Train Repairer), medically separated by the Informal Physical Evaluation Board for a left knee condition with a disability rating of 10%. 

CI CONTENTION:  He was not evaluated properly for mental health (PTSD), feet, hips, neck, sleep apnea, traumatic brain injury, shoulders and back.  His conditions continue to worsen and negatively impact his daily activities.  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:  

SERVICE PEB - 20060412	VARD - 20080327 & 20090518	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain & Instability	5009-5003	10%	Chronic Left Knee Strain	5260	10%	20060630	
Anxiety Disorder	Not Unfitting	PTSD	9411	10%	20080306	
Low Back Pain	Not Unfitting	Lumbar Strain with DDD	5243	10%	20060630	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the narrative summary (NARSUM), the CI reported he sustained an injury to his left knee on 20 June 2005 when a tire fell out of the back of his truck and struck him on the lateral aspect of his left knee.  The CI felt a pop followed by pain when weight bearing on this knee.  Clinical diagnoses included left knee ligament injuries (MCL injury/partial ACL tear).  Initial radiographic studies were normal, with an MRI consistent with previous MCL ligament avulsion and partial ACL tear.  There was no evidence of meniscal pathology.  Surgical options were discussed which the CI reasonably declined.  

At the time of orthopedic consultant exam on 28 September 2005, performed 8 months before separation, the CI reported improved range-of-motion (ROM) was improving, a shifting sensitive in the knee, slight swelling, painful popping with sharp sensation, and proximal tibia/medial joint line tenderness.  The CI reported using a brace.  Examination showed valgus laxity 2 with good endpoint, minimal swelling, negative pivot, Lachman 1A (laxity) and tenderness over the ligament insertion.  

Despite treatment including physical therapy (PT), the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a MEB.  At the MEB Narrative Summary (NARSUM) examination dated, 14 Mar 2006, 2 months prior to separation, the CI reported his left knee pain was sharp, dull and aching 60% to 70% of time with some slight swelling, but no locking.  The CI reported some catching and instability sensation 3 to 4 times per week when walking upstairs.  The NARSUM referenced the orthopedic examination from 30 November 2005, (6 months pre-separation) and detailed normal gait with trace antalgia favoring the left lower extremity, no effusion, and negative patellar apprehension.  There was tenderness to palpation over the medial femoral condyle noted.  The CI demonstrated a 1A Lachman (laxity), valgus stress test 1A (laxity), negative McMurray (meniscus exam) and negative pivot shift.  

At the VA Compensation and Pension (C&P) examination on 30 June 2006, a month after separation, the CI reported continuous pain described as dull and sharp, rated 4/10 on a pain schedule radiating up into his thigh with flare-ups occurring five times per day.  Examination showed normal tandem gait, no assistive device, no swelling, crepitus on palpation, positive McMurray (meniscus exam) sign to the left knee, stable ligaments, no evidence of subluxation, and no evidence of fluid.  

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)	Ortho ~8 Mo. Pre-Sep
	NARSUM ~2 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (140 Normal)	140	140	104	
Extension (0 Normal)	0	0	0	
Comment	Valgus laxity 2, minimal swelling, tenderness over MCL insertion at proximal tibia, Lachman 1A	Tenderness over the medial femoral condyle, 1A Lachman, negative McMurray, normal gait; valgus laxity 1A, popping and grinding, normal gait	Positive McMurray, absent Lachman, stable ligament, no decrease ROM with repeated motion, tandem gait	
§4.71a Rating	10% 	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5009-5003 code (arthritis, degenerative), citing “rated for pain, moderate/frequent.”  The VA also assigned a 10% rating using the 5260 code (leg, limitation of flexion) based on the VA C&P examination 1 month after separation.  
There was no limitation of motion, except for the ROM performed by the VA.  There was no evidence of motion limitation sufficient to rate higher than the 10% assigned and the Board adjudged that a 10% rating was supported based on functional loss (IAW VASRD §4.40 and §4.45).  The Board deliberated if dual rating of the left knee (for instability plus for ROM) was warranted; however, exams documented either instability with symptoms at the “slight” 10% criteria level under code 5257 (knee impairment for instability) with normal ROM (Service exams), or no instability with slight ROM limitation (VA exam).  The Board adjudged that there was insufficient evidence to dual rate the knee IAW VASRD §4.14 (avoidance of pyramiding).  There was no evidence of dislocated meniscus (with locking and effusion) which would achieve a higher rating under code 5258.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the anxiety disorder and low back conditions were not unfitting.  The anxiety disorder and low back conditions were not listed on the profile or implicated in the commander’s statement and were not judged to fail retention standards.  Both conditions were reviewed and considered by the Board.  

Anxiety Disorder:  The psychiatric consult dated 26 January 2006 noted this was the CI’s first appointment in Mental Health.  He did not require therapy, medication, inpatient psychiatric care nor did he miss duty or require duty limitations as a result of his difficulties.  The mental status examination was unremarkable and the diagnosis was anxiety disorder NOS.  The examiner stated that no profile was warranted.  There was no additional information to indicate that this condition interfered with the CI’s duty performance.  

Low Back Pain:  The back radiographic study completed on 16 Dec 2005, showed narrowing at L5-S1 disk, suspicious of mild compression at the T12-L1.  During the chiropractic examination on 5 January 2006, (4 month pre-separation), the CI detailed his pain was off and on.  Although the CI exam showed spasms of the paraspinal muscles, sacrospinal muscles, and iliolumbar region, the CI is released without limitation.  There was no additional information to suggest this condition interfered with the CI’s performance.  

There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance.  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 either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder and low back condition, the Board unanimously 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, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140611, 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, AR20160005028 (PD201403186)

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,
I accept the Board's recommendation and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA