RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-04248
BRANCH OF SERVICE:  Army	separation date: 20040510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Avenger System Repairer, medically separated for “left knee pain…”  with a disability rating of 0%.

CI CONTENTION:  The CI’s knees continue to worsen and negatively impact daily activities.  In addition to bilateral knees, he contends for conditions not identified by either the MEB or PEB.  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 - Dated 20040303	VARD - 20040520   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain…	5099-5003	0%	Postoperative Residuals, Left Retropatellar Pain Syndrome	5260-5024	10%	20040323	
RPPS (Retropatellar Knee Pain)	Right Knee Not Addressed by PEB	Right Retropatellar Pain Syndrome	5260-5024	10%	20040323	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Knee Pain.  The medical service records and the Medical Evaluation Board (MEB) narrative summary (NARSUM) indicated the CI fell on his left knee during an exercise at basic training, which produced immediate swelling.  Treatment the next morning was with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) and a profile.  Minimal relief was obtained; however, the CI completed basic training.  While at advanced individual training (AIT) he had magnetic resonance imaging (MRI) of the left knee.  Subsequently, arthroscopic surgical resection of a plica band on 7 January 2002 was carried out by a civilian orthopedic surgeon and the CI underwent postoperative physical therapy thereafter.  Although the CI completed AIT with intermittent discomfort and swelling of the left knee, he was seen on multiple occasions at physical therapy and orthopedics.  Range of motion (ROM) of the left knee was 0-140 degrees with pain at full flexion in September 2002.  Orthopedic evaluation in December 2002 noted the CI’s knee pain was non-operative.  In October 2003 the CI returned from deployment and indicated he used a left knee brace regularly.  Orthopedic evaluation in October 2003 revealed ROM measurements of 0-120 degrees for both the left and right knees.  Because of continued pain, the CI was recommended for an MEB, which referred “RPPS (retropatellar knee pain)” syndrome to the PEB.     

At the MEB examination on 3 December 2003, 6 months prior to separation, the CI reported his knees “give out and lock” and he had arthroscopic surgery of the left knee and used a knee brace.  The examiner did not record any physical findings related to the knees, but listed left knee pain in the summary of defects and diagnoses.

The NARSUM examination dated 3 February 2004, 3 months prior to separation, noted the CI complained of bilateral knee pain (see below for the right knee details).  His gait was normal without an obvious limp.  Evaluation of the knees revealed no effusion and there was no hypermobility of the patellar femoral joint or obvious atrophy of the VMO (vastus medialis oblique muscle of the quadriceps) or other muscular structures about the knee.  There was no crepitus (grinding) on the right or left, but there was some apprehension on the left and none on the right.  Tests for instability and meniscal tears were negative bilaterally as were stress tests on the medial and lateral collateral ligaments.  The CI had difficulty sitting for long periods and with repetitive knee bending activities such as climbing on and off of military tactical vehicles, while wearing a backpack and load bearing equipment as well as a flak vest, which produced extreme discomfort at the left more than the right knee.  Radiological studies showed no gross abnormalities on X-rays of the right or the left knee.  A permanent L3 profile was issued on 28 October 2003 and approved on 14 November 2003 for left knee and right knee pain with limitations of no running, rucking or walking on uneven surfaces.
  
At the VA Compensation and Pension (C&P) examination dated 23 March 2004, performed 2 months before separation, the CI reported pain in his right knee (see below) as he had experienced in his left knee with prolonged sitting or any activity requiring knee bending such as climbing stairs, kneeling or any running.  On examination the ROM of flexion of the left knee was 99 degrees flexion (normal 140) and with repetition it was 100 degrees; extension was 0 degrees.  Both motions were painful.  There was no crepitus, instability or evidence of a meniscal tear nor was there any erythema, warmth, or edema of either knee.  The CI had a full weight bearing non-antalgic gait.  Musculoskeletal strength was normal as was neurovascular status and he was able to bear all of his weight on one foot and was able to walk on his toes and on his heels as well as tandem walk.  The examiner’s diagnosis was retropatellar pain syndrome with increased pain with weight bearing activities and a slight decrease in ROM.  To ameliorate his condition, the CI was advised to lose some weight.  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.

Knee ROM
(Degrees)	Ortho ~7 Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	PCC ~9 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	120	120	100	108	“Intact”	“Intact”	
Extension (0 Normal)	0	0	0	0	“Intact”	“Intact”	
Comment	No laxity	No laxity	Painful motion	Painful motion	No effusion	No effusion	
§4.71a Rating	0%	00%	10%	10%	-	-	

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), citing left knee pain with a history of a fall.  The VA assigned a 10% rating using a combined 5260-5024 code (leg, limitation of extension-tenosynovitis) for the left knee based on the VA C&P examination 2 months before separation, citing postoperative residuals, left retropatellar pain syndrome (RPPS).  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45), but there was no VASRD §4.71a route to a higher rating under any applicable code.  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 pain condition, coded 5099-5003.  

Contended PEB Conditions: Right Knee Pain.  The Board’s main charge is to assess the fairness of the PEB’s lack of determination that right knee pain was or was not unfitting.  The Board’s threshold for determining or countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board first discussed whether the right knee pain condition was in scope since it was not addressed by the PEB, but was mentioned, although not explicitly in the MEB referral as RPPS (retropatellar knee pain), was contended by the CI, and was referred to as well as examined as part of the NARSUM examination, albeit with the RPPS diagnosis without any specification of which extremity or whether both extremities.  However, after an abeyance, the Board determined the right knee pain condition was in scope.  The right knee pain condition was profiled and was implicated in the commander’s statement, but was not judged whether it did or did not fail retention standards.  

Right Knee Pain.  The CI reported right knee pain and giving out for a month on 17 September 2003.  Examination revealed a full ROM with retropatellar crepitance and tenderness to pressure at the quadriceps tendon and an X-ray series demonstrated some effusion in the suprapatellar bursa, otherwise, no other abnormalities were seen.  The diagnosis of RPPS was made in the absence of injury or trauma.  The CI was referred to physical therapy and continued Motrin.   Orthopedic evaluation in October 2003 revealed the right knee ROM was 0-120 degrees and there was no laxity present.  At the VA examination flexion of the right knee was 116 degrees and with repetition it was 108 degrees; extension was 0 degrees; both motions were painful.  There was no crepitus, instability or evidence of a meniscal tear nor was there any erythema, warmth, or edema of either knee.   

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.

Knee ROM
(Degrees)	Ortho ~7 Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	PCC ~9 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	120	120	100	108	“Intact”	“Intact”	
Extension (0 Normal)	0	0	0	0	“Intact”	“Intact”	
Comment	No laxity	No laxity	Painful motion	Painful motion	No effusion	No effusion	
§4.71a Rating	0%	00%	10%	10%	-	-	
There was performance-based evidence from the record that included difficulty sitting for long periods and with repetitive knee bending activities such as climbing on and off of military tactical vehicles, while wearing a backpack and load bearing equipment as well as a flak vest, which produced extreme discomfort at the left more than the right knee.  Therefore, the Board determined the right knee condition resulted in functional interference with satisfactory duty performance at separation.  Furthermore, at the VA examination, 2 months pre-separation and the most proximate examination to separation, there was a decreased ROM with objective painful motion.  While the condition is insufficient to warrant a rating using codes for limitation of motion; nevertheless, it does merit a 10% rating for the noncompensable ROM with painful motion using code 5099-5003; however, there was no VASRD §4.71a route to a higher rating under any applicable code.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of right knee pain condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5099-5003 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the left knee pain condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended right knee condition, the Board unanimously or majority agrees that it was unfitting and 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 medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain	5099-5003	10%	
Right Knee Pain	5099-5003	10% 	
COMBINED	20% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141106, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX AR20160013789 (PD201404248)

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