RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04338
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020403

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Allied Trades Specialist (Machinist)) medically separated for right knee pain.  The right knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “right knee medial meniscal tear secondary to twisting injury” and “right knee continued symptoms of pain and swelling and locking and giving away,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “right knee pain with history of injury post surgical intervention as unfitting, rated 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.”  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the 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/Naval 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 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:  

IPEB – Dated 20011115	VA* - (~13 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5003	0%	Status Post Arthroscopic Surgery, Right Knee (Claimed as Knee Injury)	5259	10%	20030424	
Other x 0 (Not In Scope)	Other x 2	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20030617 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Knee Condition.  The first document available for review in the service treatment record (STR) was an operative report dated 8 January 1999, which indicated the CI had a 2-year history of right knee pain and an injury in October 1998.  As a result he underwent an arthroscopic partial medial meniscectomy (removal of cartilage) with a partial synovectomy (removal of the membrane surrounding the joint).  Three months post operatively the CI experienced right knee pain with running and an MRI showed “subtle PH LMT” (posterior horn lateral meniscal tear).  Treatment consisted of a brace “to catch knee if it ‘gives way’” and physical therapy.  Follow-up arthroscopy revealed no evidence of a tear of the lateral meniscus and the medial meniscus was truncated (shortened) with reasonable intact articular cartilage.  It was concluded that altered biomechanics of weight transmission in the medial side may have led to a bone contusion after resection of his medial meniscus. Postoperatively, in spite of physical therapy, the right knee pain persisted.  Orthopedic evaluation in January 2001 raised the possibility of a right iliotibial band syndrome (inflammation of connective tissue on the lateral aspect of the knee) and indicated the CI was not a candidate for a third surgery.  However, another orthopedic surgeon did consider additional surgery in March 2001, but a month later indicated the CI was not a candidate for a third surgery.

A permanent L3 profile was approved on 17 January 2001 for the CI’s right knee injury/surgery with limitations of no running, no rucking, no walking on uneven ground, and no kneeling.  On the DD Form 2807-1, Report of Medical History, dated 12 February 2001, the CI noted his knee swelled up after prolonged use, as well as locked and gave out along with constant pain.  Additionally, he had to use a knee brace to steady his knee.  The commander’s statement dated 1 March 2001 indicated the CI was unable to kneel excessively or lift heavy equipment as well as walk on uneven ground, which were requirements to set up mobile field dental equipment; however, he was able to perform his primary MOS in a clinical setting with negligible limitations, if reassigned to a TDA unit.  The MEB physical examination (DD Form 2808) dated 2 March 2001 was normal, but the examiner noted two arthroscopic surgeries of the right knee.
  
The MEB narrative summary (NARSUM) dated 17 May 2001 noted the CI sustained a right knee twisting injury in 1998 during air assault school.  In spite of physical therapy for treatment of an internal derangement of the knee, pain, swelling, locking and clicking episodes occurred.  Arthroscopic surgery was performed in 1999, which revealed a torn medial meniscus with displacement into the joint; and a medial meniscectomy was performed.  Even after rehabilitation, knee pain, swelling, locking, and giving way episodes occurred.  A second arthroscopic surgery was performed on 31 March 2000 and the findings included degenerative changes in the knee and a bruising of the anterior cruciate ligament (ACL), but no evidence of a meniscal re-tear suggested in a preoperative MRI.  Again after rehabilitation he experienced sharp pains after exercising and continued to have episodes of giving way and locking of his knee.  He could not run more than 50 feet before pain developed and continued running would invoke incapacitating pain.  A third surgery was considered, but it was felt that the CI would not benefit from it.  Physical examination of the right knee revealed no obvious deformity.  Flexion and extension ranged from 0 to 120 degrees.  There was no instability or evidence of a meniscal tear or an effusion, but there was a positive patellar grind and crepitus and tenderness along the medial joint line posterior but no tenderness to palpation in the lateral joint line.

At the VA Compensation and Pension (C&P) examination dated 24 April 2003, performed 13 months after separation, the CI reported occasional pain, swelling, locking, and popping, but he was not on any medication.  His gait was normal and there was no deformity or swelling.  The ROM of his right knee was limited from 0-130/140 degrees with no laxity.  The CI was seen on 4 June 2003 with worsening pain and locking of his right knee over the prior couple of months.  He had medial joint line tenderness, no clicking or popping with a full ROM and some tenderness at 50 degrees of flexion and no instability.  X-rays of the right knee were unrevealing, but there may have been slight joint space narrowing medially.  An orthopedic evaluation on 5 June 2003, 13 months post-separation, indicated the CI’s knee began aggravating him approximately two weeks earlier and was associated with occasional swelling, pain medially, and locking symptoms.  There was tenderness on the medial joint line with no instability, but had pain with Apley’s compression test (for meniscus injury) with a ROM to approximately 120 degrees.  At follow-up on 8 August 2003, 16 months post-separation, an MRI review demonstrated no meniscal pathology and no evidence of effusion or other ligamentous abnormalities and X-rays revealed no bony abnormalities aside for some medial compartment joint space narrowing.  Naprosyn, (naproxen, a nonsteroidal anti-inflammatory drug (NSAID), was prescribed along with physical therapy.  

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.  

Right Knee ROM
(Degrees)	MEB ~11 Mo. Pre-Sep
	VA C&P ~13 Mo. Post-Sep
	Ortho ~14 Mo. Post-Sep
	
Flexion (140 Normal)	120	130/140	120	
Extension (0 Normal)	0	--	--	
Comment	Tenderness along the medial joint line posteriorly; positive patellar grind and crepitus; no effusion	No laxity; no deformity; no swelling	Pain with Apley’s compression; tender to palpation on the medial joint line; no instability	
§4.71a Rating	0%	0%	0%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5003 (Arthritis, degenerative) for right knee pain with a history of injury post surgical intervention and indicated only one joint was involved.  The VA assigned a 10% rating using code 5259 (removal of symptomatic semilunar cartilage [a meniscectomy]) for status post arthroscopic surgery.  The Board sought a route to a higher rating.  However, in the absence of limitation of flexion to 45 degrees, extension limited to 10 degrees or instability, an additional rating could not be obtained, but use of code 5259 does afford a 10% rating option since the CI underwent a medial meniscectomy and was still symptomatic at the time of separation.  Use of code 5099-5003 for a non-compensable ROM was considered, but there were no objective findings to support its use and there was X-ray evidence of only one joint rather than two joints to obtain a 10% rating.  The Board also considered a 20% rating using code 5258 (dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion), which the CI had prior to his first arthroscopic surgery, but the arthroscopic surgery prior to separation and MRI findings post-separation failed to support a tear or dislocated semilunar cartilage.  Additionally, the locking and pain were occasional rather than frequent and there was no evidence of an effusion proximate to the time of separation.  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 right knee condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  
RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Knee  	5259	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

SAMR-RB

JUL 28 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, AR20160004469 (PD201404338)

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:
( ) D0D PDBR
( ) DVA