RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04064
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Transportation Management Coordinator, medically separated for left knee pain, rated at 0%.  

CI CONTENTION:  He was given a higher rating for his condition by the VA and 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 - 20051213	VARD - 20071127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	0%	Tear Medial Meniscus, Left Knee	5299-5259	10%	20070914	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Knee Patellofemoral Pain Syndrome.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed left knee pain with popping and grinding in 2002.  Magnetic resonance imaging studies of the knee in 4 March 2003 and 13 January 2005 both noted a medial meniscus tear.  The CI underwent diagnostic arthroscopy of the left knee in April 2005.  At the time of the surgery no meniscal (semilunar cartilage) tear, ligament or articular cartilage injury, or osteoarthritis was noted.  The knee was debrided of soft tissue (a plica band, a fibrous band on the inside of the knee which can become inflamed and a fat pad).  Following the arthroscopy, the knee pain continued and the CI was offered a second arthroscopy for debridement of scar tissue and declined.  Despite treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and so he was referred for an 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)	Ortho ~5 Mo. Post-Sep
(20050829) p.421	Ortho ~4 Mo. Pre-Sep
(20051024) p. 28	MEB (2808) ~4 Mo. Pre-Sep
(20051026) p. 34	VA C&P ~17 Mo. Post-Sep
(20070914) p.69	
Flexion (140 Normal)	130	126	130	130	
Extension (0 Normal)	0	0	0	0	
Comment	Painful motion and  crepitus, neg McMurray’s; stable	Tenderness and crepitus, neg McMurray’s; stable	stable	Painful motion; effusion; antalgic gait; tenderness; and crepitus ; no additional loss of ROM w repetition. Pos MnMurray’s; stable	
§4.71a Rating	10%	10%	0-10%	10%	

At the time of an orthopedic evaluation requested during the MEB process on 29 August 2005, 5 months before separation, the CI reported persistent anterior knee pain that was intermittent and worse when going up and down stairs.  On examination he had limited ROM as indicated in the chart above, crepitus, pain with quadriceps extension, and a positive patellar grind.  His knee was stable, he had no effusion or joint line tenderness and there was no evidence of meniscal pathology.  The diagnosis was patellofemoral syndrome and no surgery was recommended.  

At an orthopedic clinic visit on 24 October 2005, 4 months before separation, the CI reported that his left “knee [was] activity and weather sensitive.”  Running was most painful and standing for long periods of time caused pain.  He reported there had been no sustained improvement in his knee symptoms following the surgery.  The examination noted a normal gait.  Surgical scars were well-healed.  There was joint line tenderness without effusion.  There was patellofemoral compression pain, crepitus, and slight atrophy of his left quadriceps, without evidence of meniscal pathology or ligamentous laxity.  His ROM was limited as noted in the chart above.  

At the MEB examination (recorded on DD FormS 2807 and 2808) dated 26 October 2005, 4 months prior to separation, the CI reported left knee pain with running, jumping, and walking more than 2 miles.  Physical exam showed “minimal” discomfort to patellar compression, no effusion, and intact ligaments.  His ROM was limited as indicated in the chart above.  The MEB NARSUM examination cited the orthopedic examination done on 24 October 2005.

At the VA Compensation and Pension (C&P) examination on 14 September 2007, performed 17 months after separation, the CI reported painful locking and clicking of the left knee.  He also reported that “climbing stairs [was] especially difficult.”  Physical examination showed that he had an antalgic gait and walked with a brace.  There was crepitus and painful motion, without evidence of instability.  Testing for meniscal pathology was positive (positive McMurray’s test).  His ROM was limited as indicated in the chart above.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0% (coded 5099-5003, analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA rated the left knee condition 10% (coded 5299-5259, analogous to removal of symptomatic semilunar cartilage, citing symptomatic removal of semilunar cartilage based on the post-separation C&P examination.  The Board notes that the VA C&P evidence is outside the 12-month period for special consideration of post-separation VA evidence IAW DoDI 6040.44, and the C&P examinations are considered only to the degree that they provide information that reflects the CI’s condition proximate to the date of separation.  In this case, the Board judged that the remote C&P examination provided no probative evidence for its ratings recommendation at the time of separation.

The Board agreed that a 10% rating was supported coded as 5099-5003 (analogous to degenerative arthritis), an analogous code for PFS, for painful, limited motion, and 10% is the highest rating for a single major joint under 5003 rating criteria, citing the USAPDA pain policy.  There was no limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, as noted there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) with either ROM code.  The Board also noted a 10% rating could be achieved under code 5259 (Cartilage, semilunar, removal of, symptomatic), but provided no ratings benefit and there was no evidence of frequent locking with effusions or meniscal injury on exams proximate to separation to support a higher rating coded as dislocated semilunar cartilage (5258).  There was no evidence of instability or laxity (5257) and 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).  Thus, the Board determined that the evidence supports a 10% rating and no higher and chose to code as 5099-5003.  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 left knee condition.  

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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 to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain Condition	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

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

AR20160009468,

Dear 

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 Iaccept 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,

Enclosure