RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03851
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Small Arms/Artillery Repairer, medically separated for “right knee pain” with a disability rating of 10%.  

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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 - 20080819	VARD - 20090508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	Right Knee Anterior Cruciate Ligament Reconstruction with Hamstring Autograft and Bone Grafting of Tibial and Femoral Tunnels with Residual Pain	5260	10%	20090115	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Knee Pain Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain condition began in March 2005 without specific injury or trauma.  The CI had a history of anterior cruciate ligament (ACL) repair in September 2004 prior to entering military service status post-surgical repair, but he was cleared to enter military service by orthopedics in November 2005.  He was treated conservatively, but aggravated the knee when landing awkwardly after jumping off of a truck August 2007.  Pre-operative magnetic resonance imaging (MRI) studies showed disruption of the ACL graft and a possible meniscal tear and X-ray studies showed no degenerative joint changes.  The CI underwent a diagnostic arthroscopy 30 October 2007 and the ACL graft was noted to be non-functional with intact menisci and the graft was debrided.  A second surgery was performed 5 March 2008 for ACL repair and debridement of degenerative changes of the menisci.  The orthopedic follow-up visit on 16 May 2008 noted the knee joint was stable, but the CI continued with pain at the surgical site.  Further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right anterior cruciate ligament tear status-post one arthroscopic intervention prior to enlistment and then x 2 arthroscopic intervention after enlistment” and “chronic right knee pain” for PEB adjudication.

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. 

RIght Knee ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
(20080805) 	VA C&P ~2 Mo. Post-Sep
(20090115) 	
Flexion (140 Normal)	110	140	
Extension (0 Normal)	5	-10 (hyperextend-same both knees)	
Comment	Normal Gait
Painful motion
Stable
Neg. McMurray’s	Normal Gait
Painful motion
Stable
Neg. McMurray’s	
§4.71a Rating	10%	10%	

At the MEB examination dated 5 August 2008, 3 months prior to separation, the CI reported intermittent locking pain localized in the medial joint line.  The pain intensity is 4-5/10 scale and increases to 8-10/10 when aggravated by walking and driving.  The pain is relieved with rest, stretches, ice, and medication.  The MEB physical exam noted normal gait with well healed scars.  There was a well healed 4cm vertical scar localized to the mid anterior right knee.  Examination tests for ligamentous instability and meniscus pathology were negative.  There was no valgus/varus laxity.  The ROM was as recorded in the chart with painful motion.
 
At the VA Compensation and Pension (C&P) examination on 15 January 2009, performed 2 months after separation, the CI reported pain in cold weather with driving and standing for long periods.  He reported a “sense” of instability, but no frank giving-way and denied swelling or locking.  He wore a brace if he was to drive or walk for long periods.  Physical exam noted a normal gait.  Tests for ligamentous instability and meniscal pathology were negative.  There was full ROM (as recorded in the chart), without significant crepitus, but repetition caused pain.  Neurological exam was normal.  Right knee X-rays were reported as “ACL repair changes.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5099-5003, (Arthritis, degenerative), citing intermittent locking and painful motion.  The VA rated the right knee condition 10%, coded 5260, limitation of leg flexion), citing painful motion.  There was no limitation of motion which supported a 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), and there was no history of frequent locking with recurrent effusions (5258), to support a higher 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 right knee pain condition.

BOARD FINDINGS In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140809, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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, AR20160009391 (PD201403851)

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