RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04151
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070511

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E3, Medical Specialist Trainee, medically separated for “chronic left knee pain,” with a disability rating of 0%.  

CI CONTENTION:  The CI’s records were not complete, respiratory infections, seeking psychological help and a blast injury were in the missing records.  Multiple knee surgeries had prolonged recovery and long-term pain and job difficulties.  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 on 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 - 20070410	VARD - 20070501	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	S/P Left Knee Surgery with Limitation of Motion	5260	10%	20061209	
Major Depressive Disorder	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first injured his left knee in September 2003; after another injury in May 2005, he underwent surgeries in June 2005 (arthroscopic plica excision) and August 2006 (open partial patellectomy and arthroscopic debridement).  Further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left knee pain, secondary to plica syndrome and iliotibial band syndrome (status-post surgery x2)” for PEB adjudication.  

The range of motion (ROM) examinations 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)	VA C&P ~5 Mo. Pre-Sep	MEB ~2 Mo. Pre-Sep	
Flexion (140 Normal)	120	125,130,126	
Extension (0 Normal)	0	-5,-5,-4	
Comment	Painful motion; normal gait; no instability or meniscal signs; +tender; +DeLuca for pain without further ROM decrease	Pain limited; no effusion	
§4.71a Rating	10%	10%	

At the time of the VA Compensation and Pension (C&P) examination in December 2006, performed 5 months before separation, the CI reported constant knee pain elicited by physical activity along with stiffness, swelling, giving way with stairs or hills, limited endurance and limited ROM.  He had difficulty walking or running for long periods.  The examiner noted well healed knee scars and pain-limited ROM as summarized above.  

During the MEB NARSUM examination dated March 2007, 2 months prior to separation, the CI reported loss of motion, swelling at least 2 times per week (no effusion requiring drainage), giving way/buckling and use of a supporting brace.  He rated constant left knee pain at 3/10 increasing up to 7/10 with activity.  The examiner documented pain with bending and pain-limited active ROM as charted above.  Orthopedic evaluation the day prior to the NARSUM showed a positive passive patellar tilt but negative tests for instability or meniscal pathology.  There was no muscle atrophy and the CI lacked 10 degrees of full extension.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the analogous 5003 code (degenerative arthritis), with likely application of AR 635-40 (rating for mechanical limitation only), citing ROM of 0-135 degrees with pain and rated for no limitation of motion.  The VA assigned a 10% rating using the 5260 code (leg, limitation of flexion) based on the VA C&P examination 6 months before separation, citing slight limitation of motion and pain on motion.  Only the single, incomplete orthopedic evaluation documented limitation of motion which supported a rating under the diagnostic codes for limitation of extension (5261) and no exam supported ratable limitation of flexion (5260).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) on all exams in evidence.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257).  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).  Analogous rating of the plica surgery to meniscal rating was considered as persistence of pain after meniscal surgery could support a 10% rating under the analogous 5259 code (cartilage, semilunar, removal of symptomatic).  The Board adjudged that there was insufficient evidence to support frequent locking with recurrent effusions (5258), to support a higher 20% rating under that code.  There was therefore no VASRD §4.71a route to a rating higher than the 10% for painful motion.  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, coded 5099-5003.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that major depressive disorder (MDD) with anxious features was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI had a prior hardship discharge based on psychiatric problems, but did not require a psychiatric waiver at the time of his second enlistment.  A psychiatric evaluation completed on 7 March 2007, 2 months prior to separation, documented a normal mental status exam with an unhappy mood. The diagnosis was MDD (recurrent, moderate) and the examiner indicated that the CI was psychologically fit for military duty.  The MDD condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 contended MDD condition and so no additional disability rating is recommended.  

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.  In the matter of the contended MDD condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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	
Chronic Left Knee Pain	5099-5003	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

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 AR20160011603 (PD201404151)

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 10% 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