RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04073
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061019

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Mortuary Affairs Specialist, medically separated for “chronic left knee pain and instability,” with a disability rating of 10%.

CI CONTENTION:  The applicant makes no specific contention in his application.  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 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 - 20060926	VARD - 20070407	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain and Instability	5257	10%	Residual Left Knee Pain, Status Post Anterior Cruciate Ligament Reconstruction and Meniscus Repair	5257	10%	20070223	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:    

Chronic Left Knee Pain and Instability.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his knee in January 2006 during basic training when he twisted his knee and heard a loud “pop.” A physical therapy (PT) note dated 17 August 2006, recorded that the CI was status post a left anterior cruciate ligament (ACL) reconstruction and meniscus repair on 29 March 2006 and had reinjured his knee a month earlier while swimming.  Examination revealed some laxity in the ACL and the posterior cruciate ligament (PCL) was tight.  The medial collateral ligament (MCL) was loose, but not the lateral collateral ligament (LCL).  

The NARSUM physical examination dated 8 August 2006 noted the range of motion (ROM) of the left knee was 0-130 degrees with pain at extreme ROMs.  The CI had no excessive laxity varus/valgus stress and had a 1+ Lachman’s with a solid endpoint, a negative pivot shift test, and negative anterior drawer testing.  He had a mild effusion over the knee.   

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated August and September 2006 and 1 month prior to separation, the CI reported that he had surgery on his left knee, ACL and meniscus.  The examiner noted a positive McMurray’s test (to determine a meniscal tear).  

A post-separation MRI dated 30 November 2006 revealed the ACL repair with good positioning of the graft and a slightly increased signal at the femoral attachment.  Surgical changes involved the medial meniscus.  Slight stranding of the MCL was noted and clinical correlation was recommended.  At an orthopedic evaluation on 21 February 2007, approximately 4 months post-separation, the CI reported persistent symptoms and noted the knee popped occasionally.  Examination of the left knee revealed full ROM.  There was a small effusion without crepitus.  There was a 1.5 plus opening at valgus stress, but was stable to varus stress testing.  The CI had a positive Lachman’s test (to determine instability) at about 2+ and he had a positive pivot shift test.  The posterior drawer test (to determine stability of the PCL) was negative and there was a trace of some external rotation recurvatum (to determine opening of the knee).  There was mild tenderness on the medial joint line; the lateral side was nontender.  The right knee was stable without laxity.  Surgical revision of the ACL reconstruction was recommended because of significant loosening and a positive pivot shift test.

At the VA Compensation and Pension (C&P) examination dated 23 February 2007, performed 4 months after separation, the CI reported a torn meniscus after an ACL and meniscal repair.  He felt grinding and the knee was not stable.  On examination the left knee joint lines were tender and there was a positive McMurray’s test.  Joint laxity was present with an anterior drawer test with moderate to severe laxity greater than 6 mm.  The left knee ROM demonstrated extension to 0 degrees and flexion 0-142 degrees.  There was no pain with the ROM and no loss of motion with repetition.  X-rays demonstrated a slight deformity of the alignment of the left knee with a radiolucent area in the anterior left tibia with a sclerotic margin, which could be the residual of the old cruciate tendon repair.  The remainder of the right and left knees were within normal limits.  

On 5 March 2007, approximately 5 months post-separation, the CI underwent a left knee arthroscopy with a partial medial meniscectomy, partial lateral meniscectomy and bone graft for the previous ACL tendon [graft insertion] on the tibial side.  On examination in April 2007, 1 month status post the ACL tunnel bone graft, the CI had a good ROM with a 1+ effusion.  He was advised to use his custom knee brace during physical activities and at work, but he was otherwise restricted from twisting, turning, kneeling and squatting. On 8 May 2007, the ROM for extension was 0 degrees and flexion was 0-142 degrees without pain on motion or loss of motion or pain on repetition.  In a note dated 28 September 2007, the CI complained of knee pain after he walked on hard concrete and it was worse with any activity and was better with rest.  On examination the left knee was stable with multiple incision sites of prior surgery, but pain was elicited with crepitus on motion.  

The 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)	PT ~2 Mo. Pre-Sep
	MEB ~1 Mo. Pre-Sep
	VA C&P ~5 Mo. Post-Sep
	
Flexion (140 Normal)	134/137/135	130	0-142	
Extension (0 Normal)	3/4/4	0	0	
Comment	Pain 3/10	Pain at the extreme ROMs; no excessive laxity varus/valgus stress; 1+ Lachman’s with a solid endpoint; negative pivot shift test; negative anterior drawer testing	No pain on motion; no loss of motion on repetition; anterior draw with moderate to severe laxity > 6mm	
§4.71a Rating	PEB 10%	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% using code 5257 (knee impairment-slight recurrent subluxation or lateral instability) for chronic knee pain and instability.  The VA assigned a 10% rating using code 5257 for residual knee pain, status post anterior cruciate ligament reconstruction and meniscus repair.  The Board noted the CI did have instability, but Board members did not find evidence consistent with either moderate or severe instability to warrant a higher rating prior to separation and during the VA C&P examination.  Nevertheless, at the VA examination, approximately 1 month prior to separation, the CI had pain only at the extremes of the ROMs and no pain on motion or on repetition thereby likely precluding an additional rating for painful motion in the knee.  However, the CI underwent surgery on the left knee 5 months post-separation (IAW code 5259-removal of (semilunar) meniscal cartilage) and 1 month postoperatively had a full ROM without pain and no mention of instability.  Although the CI underwent partial meniscectomies post-separation, the record was silent related to frequent episodes of “locking” pain and effusion into the joint IAW code 5258.  The Board members considered use of that code at 20%, but noted within a month postoperatively there was no recorded painful motion on examination. The Board was unable to find a route to a higher rating in the absence of ankylosis, moderate or severe recurrent subluxation or lateral instability, limited flexion or extension, or tibia and fibula impairment.  Furthermore, the Board members noted combining code 5259 with either code 5257 or 5099-5003 would raise the issue of pyramiding, which is to be avoided.  The Board members also discussed whether code 5099-5003 was more accurate than using the code 5257 for the final rating at 10%, but since there was no rating change, a change of code would not offer any benefit to the CI.  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 the left knee pain condition.  

BOARD FINDINGS:  In the matter of the left 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, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						
18 AUG 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 AR20160011801 (PD201404073)

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