RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04329
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081007

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Trainee, medically separated for “right knee pain,” 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 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 - 20080924	VARD -20090428	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	Residual of Right Knee, Status Post-Surgical Repair	5299-5257	0%	--	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a right knee anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft in 2002 which did not require a waiver for service entry on 3 April 2008.  He reinjured his right knee during basic training in April 2008 and underwent surgery on 30 May 2008 for repair of an ACL graft rupture and a medial meniscal tear with a patellar chondroplasty.  Despite the surgery and extensive physical therapy, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for a MEB.  The MEB forwarded “right recurrent ACL rupture, status post revision ACL reconstruction,” “right medial meniscal tear,” and “right knee chondromalacia” to the PEB for adjudication.  

At the NARSUM examination dated 14 July 2008, 3 months prior to separation (1 month after surgery), the CI had pain and functional limits from his right knee.  On examination, he had an antalgic limp on the right leg, full range of motion, no effusion, and no significant joint line tenderness to palpation.  Provocative maneuvers indicated a 1A Lachman’s (slight ligament laxity) while anterior/posterior drawer and pivot shift tests were negative.  Atrophy of the thigh musculature was noted on the right compared to the left and strength was “graded as 4+/5 in the thigh and hamstring muscles secondary to postoperative weakness.” The NARSUM addendum dated 17 September 2008, 1 month prior to separation (4 months after surgery), indicated that both knees had goniometric range of motion (ROM) from 0-140 degrees (normal).  

The CI did not attend his scheduled VA Compensation and Pension (C&P) examination.  However, he sought VA emergency care on 8 December 2008 (2 months after separation) for a right knee injury while playing baseball.  Diagnostic imaging showed a loose body in the knee (intra-articular osseous body anteriorly) with a questionable small effusion and “no convincing evidence of an acute fracture.”  The CI again visited the emergency room the same month for another right knee injury while playing basketball, however, he left without being seen.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded analogously as 5099-5003 (degenerative arthritis), citing painful motion.  The VA rated the right knee condition 0%, coded analogously as 5299-5257, (knee, other impairment of), citing unavailability of service medical records and no evidence showing a current disability level since the CI failed to report for his C&P examination.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion or functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  It was agreed that frequent locking due to dislocated semilunar cartilage was not present, and therefore a 20% rating was not justified under the 5258 code.  However, Board members' consensus was that, given the signs of ACL laxity 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 positive Lachman’s test for laxity and noted the objective examination findings of instability were no more than mild.  The Board agreed that this evidence most accurately described “slight” instability under the 5257 code.  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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends an additional disability rating of 10% for knee instability, coded 5299-5257, for a combined rating of 20% for the right knee condition.  

BOARD FINDINGS:  In the matter of the right knee condition, the Board majority recommends dual rating of the knee with a disability rating of 10%, coded 5099-5003, and 10%, coded 5299-5257 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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	
Right Knee Pain 	5099-5003	10%	
Right Knee Instability	5299-5257	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated w/attachments
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 AR20160011360 (PD201404329)

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, 
I reject the Board’s recommendation and hereby deny the individual’s application.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.

2.  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:

CF: 
(  ) DoD PDBR
(  ) DVA