RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03376
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Petroleum Supply Specialist, medically separated for “left knee retropatellar pain syndrome,” with a disability rating of 10%.  

CI CONTENTION:  The applicant requests consideration of all conditions in his 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 - 20080801	VARD - 20090521 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee … Pain Syndrome	5099-5003	10%	Left knee Degenerative Joint…	5260	10%	20090116	
Intermittent Back Pain	Not Unfitting	Degenerative …Lumbar Spine	5242	10%	20090116	
Right Shoulder Pain	Not Unfitting	Right Shoulder Impingement…	5201	10%	20090116	
Headaches	Not Unfitting	Migraine Headaches	8100	0%	20090116	
Right Hand Fractures 	Not Unfitting	Right Hand Fractures	Not Rated	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Left Knee Retropatellar Pain Syndrome.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee pain began in November 2004 while running.  The knee pain was worse ascending and descending stairs.  Subsequently he experienced chronic left knee pain diagnosed as retropatellar pain syndrome (pain arising from the joint between the knee cap, patella, and the thigh bone, femur).  Radiographic study (magnetic resonance imaging [MRI]), 7 March 2007, identified no significant abnormalities (there was a small joint effusion and mild degenerative signal in the meniscus without tear; all ligaments intact, normal joint cartilage).  A repeat MRI, 15 July 2008 showed subtle degenerative change of the medial meniscus unchanged from the prior study and was otherwise normal.  At the time of an orthopedic examination 3 March 2008, the CI reported chronic left anterior knee pain without instability.  On examination there was tenderness of the anterior knee with compression of the knee cap. The tracking and excursion of the patella (knee cap) was normal.  There was no effusion or instability and the range-of-motion was normal.  Despite treatment, physical therapy (PT), and the determination the CI was not a surgical candidate, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a Medical Evaluation Board (MEB).  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.        

Left Knee ROM
(Degrees)	Orthopedics
~8 Mo. Pre-Sep	Clinic ~7 Mo. Pre-Sep	PT ~6 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (140 Normal)	135	135	80,78,78	130	
Extension (0 Normal)	0	0	              5,2,3	0	
Comment	Tender patellar tendon
No ligament instability
No meniscus signs	Tender patellar tendon
No ligament instability
No meniscus signs	ROM limited due to pain and pts willingness to move through the pain.	No change after repetition.
Painful motion.
Tenderness.
No ligament instability.
Antalgic gait	
§4.71a Rating	10%*	10%*	10%*	10%*	
   *Considering painful motion and functional loss

At the MEB NARSUM examination on 16 May 2008, (8 months prior to separation) the CI reported constant pain 6/10 in his left knee with decreased ROM preventing him from running, jumping or repetitive bending of his left knee.  He reported his pain at 6/10 with exacerbations resulting in the pain reaching 7/10.  Physical exam showed positive patellar grind, and slight tenderness to palpation about the medial aspect of the joint line.  There was no swelling, ligament instability, or examination signs of meniscus problems.  Strength and gait were noted as normal.  At the time of the orthopedic consultant appointment on 30 May 2008, (8 months prior to separation), the CI reported chronic anterior knee pain with pain mediated give-way symptoms.  On examination there was tenderness of the patellar tendon. The ROM was normal (see chart) and there was no ligament instability or meniscus signs.  The diagnosis was patellofemoral syndrome.  The CI presented to clinic on 25 July 2008 with increased symptoms including give way symptoms due to pain, but no locking.  The examination was unchanged from the prior orthopedic examination (see chart).  The physical therapy MEB ROM examination, 3 September 2008, is recorded in the chart.  There was limitation of motion due to pain.  

At the VA Compensation and Pension (C&P) exam, 16 January 2009, (a month before separation), the CI reported constant pain, weakness, stiffness, fatigue and lack of endurance causing difficulty walking or running long distances and navigating stairs.  The VA examiner noted the condition had been gradual and progressive in nature.  On examination, the CI exhibited an antalgic gait and guarding the left knee.  There was tenderness to palpation but no swelling or effusion, and no ligament instability.  There was limitation of motion with painful motion (see chart).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under 5099-5003 (left knee retropatellar pain syndrome) citing painful motion in the face of preserved ROM.  The VA assigned a 10% rating under 5260 (left knee degenerative joint disease) based on the VA C&P examination a month before separation, citing painful motion.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), frequent locking with effusions or any indication of dislocated meniscus or loose body (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 retropatellar pain syndrome condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the intermittent back pain, right shoulder pain, headaches, and right hand fracture conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The back pain, right shoulder pain, headaches, and hand conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards. All were reviewed and considered by the Board.   There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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 the any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the left knee retropatellar pain syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended intermittent back pain, right shoulder pain, headaches, and right hand fracture conditions, 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 20140707, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008001 (PD201403376)

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