RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03992
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20081227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Unit Supply Specialist, medically separated for “leg, limitation of extension [right knee],” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  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 based upon a 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 - 20081028	VARD - 20090909	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Leg, Limitation of Extension (Right Knee)	5003-5261	10%	Post Traumatic, Postoperative Medial Collateral Ligament Laxity, Right Knee with Post Traumatic Arthritis. (Claimed as Knee Problems)	5010-5261	10%	20090429	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Right Knee Leg Limitation of Extension.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had three right knee surgeries (1988 – open MCL repair, 1996 – lateral meniscus repair, and 2003 – lateral meniscus repair and meniscal cyst removal) and was medically separated in 2003 for his right knee.  The CI was subsequently recalled to duty in 2006 and reinjured his right knee in March 2008.  Diagnostic imaging in July 2008 showed osteoarthritic changes, lateral meniscus intrasubstance and degenerative changes and a cyst, and chondromalacia patella.  At the time of the orthopedic consult dated 6 August 2008, the CI complained of right knee pain, locking and giving out.  He wore a brace to walk around the house and used crutches to ambulate any distance.  Physical examination showed well healed surgical scars with knee tenderness.  There was pain-limited motion to 118 degrees flexion (normal 140) and extension to -10 degrees (normal 0).  There was medical collateral ligament (MCL) laxity.  The orthopedic surgeon indicated that there was no indication for further surgery, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic pain right knee” and “osteoarthritis right knee” for PEB adjudication.

The MEB NARSUM examination on 2 September 2008, 3 months prior to separation, noted complaints of right knee pain, and “He requires a knee brace to be worn at all times to keep his knee from buckling.”  He could not run, squat or carry over 15 pounds.  Physical examination showed a knee brace in place.  There was laxity of the MCL and flexion to 120 degrees and extension to -8 degrees.  The diagnosis was “chronic pain right knee, osteoarthritis right knee.”

The MEB NARSUM Orthopedic examination on 17 October 2008, 2 months prior to separation, was in answer to PEB questions on MCL laxity and degree of chondromalacia.  The examiner noted complaints of non-radiating knee pain with locking and giving out.  The CI wore a brace 90% of the time for knee stability.  Physical examination showed painful motion with flexion of 95 degrees and extension to -5 degrees.  “There was a negative drawer and a negative Lachman’s.  He was stable to varus/valgus stress at zero and 30 degrees;” however, the remaining portion of the examination on stability testing was incomplete in the evidence of record (missing page).

There was no VA Compensation and Pension (C&P) evaluation proximate to separation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded 5003-5261 (degenerative arthritis - leg, limitation of extension), citing extension limit of -5 degrees and painful motion.  The VA rated the right knee condition 10%, analogously coded 5010-5261 (arthritis, due to trauma - leg, limitation of extension) based on the VA C&P examination 3 years prior to separation (prior to additional knee injury), citing limited extension and likely aggravation.  The subsequent VARD dated 9 September 2009 made no change to the original VA rating.  The CI had prior meniscal surgery with diagnostic imaging abnormalities of the meniscus and osteoarthritis.  There were symptoms of giving way and locking of the knee with required use of a brace.  There was no limitation of motion which supported a rating higher than 10% as adjudicated by the PEB under the diagnostic codes for limitation of flexion or extension (5260, 5261) including evidence of painful motion (based on §4.59).  Alternative coding analogous to 5259 (cartilage, semilunar, removal of, symptomatic) includes painful motion and would not result in a higher rating than awarded by the PEB.

It was agreed that frequent locking due to dislocated semilunar cartilage (meniscus) was not clearly documented, and therefore a 20% rating was not justified under the 5258 code.  However, Board members concluded that, given the symptoms and signs of right knee instability in this case, dual coding was appropriate.  In deliberating a rating under the 5257 code (knee, other impairment of; recurrent subluxation or lateral instability), the Board considered the objective examination findings by the orthopedic and NARSUM examiners 5 and 3 months prior to separation of MCL laxity and knee instability.  The Board agreed that this evidence most accurately described “slight” (10%) instability under the 5257 code.   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separation rating of 10% for (painful motion) coded 5003-5261, and 10% for knee instability coded 5257, for a combined rating of 20% for the right knee condition.

BOARD FINDINGS:  In the matter of the leg, limitation of extension (right knee) condition, the Board unanimously recommends a disability rating of 10% for painful motion coded 5003-5261, and 10% for knee instability coded 5257, both IAW VASRD §4.71a.  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 the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Leg, Limitation of Extension and Instability (Right Knee)	5003-5261	10%	
	5257	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140918, 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

02 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017763 (PD201403992)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA