RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03427
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Tracked Vehicle Mechanic, medically separated for “right knee pain,” with a disability rating of 10%.  

CI CONTENTION:  “Please consider all conditions.” The applicant’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 - 20060926	VARD - 20070501	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in Right Knee…1B Lachman	5257	10%	Degenerative Joint Disease, Right Knee…	5010-5260	10%	20060725	
Neck Pain	Not Unfitting	Degenerative Arthritis, Cervical Spine	5242	0%	20060725	
Lumbago	Not Unfitting	Degenerative Arthritis, Lumbar Spine	5242	10%	20060725	
Left Hip Pain, Arthritis	Not Unfitting	Left Hip Strain	5299-5252	NSC	20060725	
Atypical Depressive Disorder	Not Unfitting	No VA Placement	
Headaches, Tension Type	Not Unfitting	No VA Placement	
Hearing Loss	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Knee Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially injured his right knee during basic training for the Marine Corps in 1989.  He underwent an arthroscopic debridement in 1992 but was discharged before a planned ACL repair was accomplished.  The CI returned to active duty in 2001 and by June 2002, he had increased problems with running.  Magnetic resonance imaging (MRI) findings in April 2003 showed an absent anterior cruciate ligament, a small joint effusion, an osteochondral defect in the medial femoral condyle, an abnormal medial meniscus, and an abnormal lateral meniscus with degeneration in the posterior horn and a question of a short concentric tear in its mid-portion.  In May 2004, the CI underwent knee reconstruction of the ACL.  He deployed for a year thereafter and had pain and swelling, but functioned with the pain.  A CT scan of the right knee in November 2005, demonstrated a prior ACL repair, chondrocalcinosis (calcification of cartilage), osteoarthritis, and a healed OCD (osteochondritis dissecans) in the inner side of the medial condyle.  An orthopedic evaluation in December 2005 found anterolateral rotary instability of both knees with a failed ACL on the right.  In December 2005 the CI underwent arthroscopy and had a revision of the ACL with an allograft, removal of linterarticular loose bodies and removal of a proximal tibia screw.  Postoperative physical therapy was carried out thereafter.  Examination in February 2006 revealed a range-of-motion (ROM) of extension to -5 degrees and flexion to 110 degrees.  There was a 1A Lachman (a test of instability) and moderate quadriceps atrophy.  At an orthopedic examination in April 2006, the CI’s knee was stable with mild medial and lateral joint pain and mild discomfort on the patellofemoral area.  A steroid injection was carried out with consideration of a Synvisc (hylan, to lubricate the joint) injection if he remained symptomatic.  In June 2006, the CI complained of significant medial and lateral joint line pain.  Imaging revealed medial and lateral degenerative joint disease.  A permanent L3 profile was issued in April 2006 for right knee pain, arthritis, an old ACL reconstruction, and revision.  Additional diagnoses were included in the profile, in which there were limitations of physical fitness testing and all military functional activities except wearing a protective mask and all chemical defense equipment.  Additionally the CI was to perform activity at his own pace and distance only.  

At the MEB examination, the CI reported (on DD Form 2807-1 dated 8 June 2006) that he had his right ACL replaced 2 times and had a plate and screws in the right knee.  The MEB physical examiner noted an old healed anterior medial scar and a +/- patellar grind and recorded right knee pain with osteoarthritis and old ACL reconstruction times two as the diagnosis.  The commander’s statement dated 6 July 2006, indicated the CI was physically incapable of performing his duties as a mechanic due to arthritis/meniscal deficiency in the right knee and that he was non-deployable. 

At the VA Compensation and Pension (C&P) examination dated 25 July 2006, performed 4 months before separation, the CI reported burning and sticking pain in the right knee for 3 years with a pain level of 5/10 (10 being the worst pain); and, he had difficulty with prolonged sitting and standing.  On examination, the right knee showed signs of tenderness and guarding of movement.  Flexion was 130 degrees with pain at 130 degrees.  The joint function was additionally limited 12 degrees by pain, fatigue, and lack of endurance with repetition.  The cruciate stability tests of the right knee were normal as were the collateral ligaments and the meniscal tests.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

Right Knee ROM
(Degrees)	PT ~8 Mo. Pre-Sep
	MEB ~5 Mo. Pre-Sep
	VA C&P ~4 Mo. Pre-Sep
	
Flexion (140 Normal)	125	135	130	
Extension (0 Normal)	0	0	0	
Comment	Normal gait; stood with knee 5 degrees of flexion; negative effusion; slight pain with hyperextension	Mild antalgic gait; positive anterior right drawer sign and a 1B Lachman (slight instability); no meniscal tear	Pain at 130 degrees; repetition limited joint function by 12 degrees; tenderness and guarding	
§4.71a Rating	0%	PEB 10%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5257 (knee impairment-recurrent subluxation or lateral instability) for chronic pain in the right knee, status post ACL injury delayed reconstruction and subsequent revision.  The VA assigned a 10% rating using code 5010-5260 (arthritis due to trauma-leg, limitation of flexion) for degenerative joint disease of the right knee status post-surgery.  The Board sought a route to a higher rating.  Based on a VA Counsel General opinion dated 1 July 1997, which permits instability (5257) to be combined with arthritis (5003), the Board agreed that since the CI had a non-compensable ROM of the right knee with painful motion, the use of code 5099-5003 for an additional 10% rating is applicable in this case.  However, in the absence of ankylosis, moderate subluxation, meniscal dislocation, more limited flexion and/or extension, and tibia and fibula impairment the Board was unable to find a route to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a combined disability rating of 20% for the right knee condition using code 5257 at 10% and code 5099-5003 at 10%.

Contended PEB Conditions.  

Neck (Cervical Spondylosis with Cervicalgia) Condition.  The CI had chronic headaches and some neck pain.  X-rays and an MRI of the cervical spine showed moderate multilevel degenerative disc disease (spondylosis), facet hypertrophy, disc bulges at C4-5, C5-6, and C6-7 and indentations of the thecal sac.  Surgical intervention was not recommended and electro-diagnostic studies were negative for radiculopathy or other peripheral neuropathy.  In August 2006, the CI indicated he had moderate pain of the posterior neck inferiorly on the right for a few months after wearing body armor.  Neurologic examination was normal.  As a result the CI could not do sit-ups due to neck pain.  

Cervical ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
	VA C&P ~4 Mo. Pre-Sep
	
Flex (45 Normal)	30	45	
Extension (45)	40	45	
R Lat Flexion (45)	40	45	
L Lat Flexion (45)	40	45	
R Rotation (80)	70	80	
L Rotation (80)	70	80	
Combined (340)	290	340	
Comment	TTP along the C-spine 2-3+/4; painful motion	DeLuca negative; no evidence of radiating pain on movement; no muscle spasm; no ankylosis	
§4.71a Rating	No PEB Rating	VA 0%	

The neck condition was profiled U3, while the back, hip, headache, depressive disorder, and hearing loss conditions were profiled P2, S2, or H2.  None of the conditions were implicated in the commander’s statement and none were judged to fail retention standards except for the neck.  All were reviewed and considered by the Board.  While the neck condition was discussed in depth, the Board concluded that there was no performance based evidence from the record that any of the 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 any of contended conditions  and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB’s current adjudication of a 10% rating under VASRD code 5257, but also recommends adding a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a for a combined disability rating of 20%.  In the matter of the contended neck (cervical spondylosis with cervicalgia), back (lumbago), left hip pain/arthritis, headache, tension type, atypical depressive disorder, and hearing loss 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 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	
Right Knee Recurrent Subluxation	5257	10%	
Right Knee Osteoarthritis	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140702, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160008014,  XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

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,