RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03635
BRANCH OF SERVICE:  Army	BOARD DATE:  20150212
SEPARATION DATE:  20070615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Calvary Scout) medically separated for a right knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “patellofemoral syndrome” to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded “migraine headaches” as medically acceptable.  The Informal PEB adjudicated “chronic pain right knee, due to patellofemoral syndrome” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  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/Naval 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 IPEB – Dated 20070507	VA* - (4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Right Knee	5099-5003	0%	Degenerative Arthritis Right Knee	5260-5010	10%	20071004	
			Instability Right Knee	5257	10%	20071004	
Migraine Headaches	Not Unfitting	Migraine Headache	8100	10%	20071004	
Other x 0 (Not In Scope)	Other x 7	
RATING:  0%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20071016 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:

Right Knee Condition.  Service treatment records (STR) indicate the CI developed right knee pain in February 2005 while sprinting and stepped into a hole causing a hyperextension injury.  He had knee pain especially with bending, squatting, running, and going up stairs.  He rated pain at 8/10.  Patellar tendonitis was diagnosed and he received a L2 profile that restricted his movement.  A home exercise program, a patellar tendon strap, and a non-steroid pain medication did not relieve the pain.  The pain was worse at night and relieved only by a narcotic medication.  X-rays and magnetic resonance imaging of the right knee were always normal.  A diagnosis of patellofemoral syndrome was made.  Despite the chronic right knee pain, he deployed to Iraq from 17 May 2005 to 19 April 2006.  While in-theater, he reported a “stinging pain underneath kneecap” with aching and swelling after prolonged sitting and activity, aggravated by sitting, jumping, and walking.  Examination of the knee showed a full range-of-motion (ROM) and no instability.  Orthopedics later diagnosed patellar chondromalacia and conducted an arthroscopy on 27 April 2006 that was normal.  Pain persisted and he developed some stiffness at rest that resolved with motion while working as a truck driver.  He continued to have difficulty with running, climbing stairs, and performing normal activities of his duty assignment.  He received an L3 profile on 13 March 2007.

At the narrative summary (NARSUM) exam dated 23 March 2007, 3 months prior to separation, the CI reported the pain in his right knee prevented him from performing military duties specific to his MOS.  He could not wear his rucksack or flack vest, could not jump on and off vehicles or climb stairs, and was unable to ruck.  He could not play with his children, drive for more than a short period, mow the yard, or play sports.  Physical therapy conducted an examination of the right knee on 14 March 2007 that revealed no swelling, redness or bruising, or evidence of instability.  Gait was non-antalgic and without assistive devices.  The test for crepitus and pain was positive.  ROM showed extension of 0 degrees bilaterally (normal), flexion of 125 degree left (normal 140), 120 degrees right (normal 140), and active assisted flexion 125 degrees on the right.  Bilateral lower extremity strength was 5/5 with decreased effort during right leg extension due to pain.

At the VA Compensation and Pension exam dated 4 October 2007, performed 4 months after separation, the CI reported he had pain in the right knee that was constant, traveled proximal and distal to the knee, was squeezing, aching, sharp and cramping in nature.  The pain level was at 10, could be elicited by physical activity, and could be relieved with pain medication although he could function without it.  He also received physical therapy.  He experienced stiffness in the knee; it was hard to stand from a sitting position.  There was transient swelling that was worse with driving or standing/walking a lot.  It gave way spontaneously and it locked when driving or bending a short time.  He denied heat, redness, lack of endurance, fatigue and dislocation.  The CI could perform activities of daily living but could not climb stairs, walk, shop, garden, or push a lawn mower because of the pain.  He had been employed as a print technician since 2004.  He had a normal gait and did not require an assistive device for walking.  Examination of the right knee showed tenderness and guarding of movement without swelling, weakness, redness, subluxation or locking pain.  ROM of the right knee revealed flexion 140 degrees (normal), extension 0 degrees (normal).  Joint function was limited after repetitive use by pain, fatigue, and lack of endurance by 40 degrees.  There was stability of the ligaments in the right knee joint but the medial and lateral meniscus test was abnormal (suggesting a possible tear) with a slight degree of severity.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5099-5003 code (degenerative arthritis) with likely application of AR 635-40 (rating only on mechanical loss of motion).  The VA rated the degenerative arthritis of the right knee condition 10%, coded 5260-5010 (leg limitation of motion and arthritis due to trauma), and also rated the right knee at 10%, coded 5257 for instability citing abnormal meniscus testing.  The Board agreed that there was sufficient evidence of painful motion to warrant a 10% rating for the right knee IAW VASRD §4.59 (painful motion).  Other pathways to a higher rating were considered.  Since ankylosis was not present, rating under 5270 or 5272 was not supported.  There was no compensable ROM for a higher rating.  The Board considered if dual rating for instability was supported.  There was no instability in the service exam, and the VA abnormal “meniscal tests” were not considered to be instability.  If meniscal rating analogous to code 5259 (Cartilage, semilunar, removal of, symptomatic) were considered, it would include any painful motion rating.  A higher rating under 5258 (Cartilage, semilunar) was not supported as there was insufficient evidence of frequent episodes of “locking,” pain, and effusion into the joint.  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 right knee condition.

Migraine Headache.  The Board’s main charge is to assess the fairness of the PEB’s determination that migraine headaches condition was not unfitting.  The Board’s threshold for countering fitness determinations is preponderance of the evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The last STR regarding migraine headaches prior to separation, dated March 2007, indicated they had been present since his return from Iraq in 2005 but were well controlled with medication.  There was a question of side effects due to his migraine medication.  The MEB physical, DD Form 2808, listed a diagnosis of migraine but indicated it was “not unfitting at this time.”  The NARSUM noted the “migraine headaches were being treated with moderate success.”  A review of the CI’s appeal regarding headaches did not find evidence they were unfitting.  The migraine headaches were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that migraine headaches 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 that the contended migraine condition was unfitting and so no additional disability ratings are recommended.

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 AR 635-40 for rating the knee condition was likely operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the chronic right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended migraine headaches the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: 

UNFITTING CONDITION	VASRD CODE	RATING	
Right knee pain Condition	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150011220 (PD201403635)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization 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:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA