RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00032
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Petroleum and Supply Specialist, medically separated for “left knee pathology with chief complaint of knee pain” and “patellofemoral syndrome with right knee pain,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:  “Please consider all conditions and evidence”.  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 - 20061030	VARD - 20080320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain [Surgical Residuals]	5299-5257	0%	Left Knee Retropatellar Pain Syndrome (RPPS) ...	5299-5257	NSC	STR*	
Patellofemoral Syndrome, Right Knee	5099-5003	0%	Right Knee RPPS ...	5299-5257	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	
*Failed to show

ANALYSIS SUMMARY:

Left Knee and Right Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left knee (“twisting/valgus stress”) during training in April 2005.  He was diagnosed with a left anterior cruciate ligament (ACL) tear and underwent ACL reconstructive surgery (allograft) in October 2005 (13 months before separation).  It was unclear from the STR when the right knee became symptomatic.  There were orthopedic entries addressing the left knee injury prior to surgery which provided comparison examinations with the right knee, but with no indication of associated complaints.  Of note, one of these, although noting a positive Lachman (ACL laxity) on the left and a negative one on the right, entered “anterolateral rotary instability with no active pivot shift” for both knees.  Another recorded a “Lachman 2b” finding with an otherwise normal examination for the asymptomatic right knee.  Magnetic resonance imaging (MRI) for the right knee was ordered in February 2006 (4 months after the left knee surgery), suggesting that symptoms were present, although the earliest STR entry that documented bilateral complaints was three months later.  The right knee MRI demonstrated a “mild” bone contusion (femoral condyle), although there was no preceding (or subsequent) documentation of a right knee injury; and, that same MRI reported intact menisci and all four ligaments.  A post-operative MRI of the left knee raised the possibility of a meniscal injury (“medial meniscus is not well-defined and may be torn”), but all ligaments were intact.  It was judged that further surgery for the left knee was not indicated, and there were no surgical indications for the right knee.  Bilateral pain persisted and continued treatment did not result in sufficient improvement to allow unrestricted duty.  The CI was referred for an MEB which in turn forwarded “bilateral painful knees” to the PEB.

The only measured range of motion (ROM) evidence in the STR file was for the left knee (orthopedics, 10 months before separation), and documented flexion to 135 degrees (normal 140, 45 for minimum 10%) and extension 0 degrees (normal).  The majority of ROM observations for both knees were grossly normal, and there were no entries indicating significant limitation of either knee.  There was occasional note of non-specifically decreased ROM for the left knee with documentation of painful motion; and, there was documentation of pain with use (VASRD §4.40 as below) for both knees.  There were multiple STR entries documenting stability to stress testing for both knees, with the occasional caveat for both knees of the finding “anterolateral rotary instability with no active pivot shift” as noted above.  The CI denied subjective instability (“doesn’t give way”) and there was no indication that he required a brace for either knee (after post-operative rehabilitation).  The majority of entries noted the absence of effusion or signs of impingement.

The MEB NARSUM examination on 30 June 2006 (5 months before separation) documented that the CI “never was asymptomatic” for his left knee after surgery and “now he is having problems with his right knee” with functional limitations of inability to run or load bear.  The physical examination recorded a “mild” effusion on the left, tenderness, tight hamstrings with residual atrophy bilaterally, and “stable on ligament testing” (unclear if left only or bilateral).  There was no comment regarding ROM, although an STR entry after the MEB NARSUM documented grossly normal bilateral ROM.  As below, there was no temporally probative post-separation evidence.

The Board directed attention to its rating recommendations based on the above evidence.  The PEB rated the left knee 0%, coded analogously to 5257 (knee, other impairment of [subsuming recurrent subluxation or instability]), citing “does not meet the minimal rating criteria.”  The PEB’s 0% right knee rating was coded analogously to 5003 (degenerative arthritis), citing “as there is only one joint involved.”  As charted above, the VA did not service-connect either knee, citing unavailability of service records as requested and failure to show for examination.  There was no minimum compensable ROM limitation in evidence; but, members agreed that VASRD §4.59 (painful motion) and/or §4.40 (functional loss) was adequately documented in support of the minimum compensable rating (10%) for both knees.  There was insufficient evidence for frequent locking and effusion to support a 20% rating under code 5258; and, no fracture or other finding to support a rating higher than 10% under any applicable code.  Members considered whether the STR references to anterolateral rotary instability (possibly the justification for PEB coding of the left knee) was sufficient evidence in support of additional rating for instability (code 5257) for either knee.  It was considered, however, that this more likely than not represented an anatomic baseline for the CI.  All examiners recorded normal stress testing in all planes except for this caveat; there was MRI confirmation of intact ligaments; and, there was no documentation of any functionally significant instability.  Members thus agreed that additional rating for instability was not justified for either knee.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for each knee; proposing code 5099-5010 (traumatic arthritis) for the left knee and code 5099-5024 (tenosynovitis) for the right knee.

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5010 IAW VASRD §4.71a.  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 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	
Ligamental Injury with Surgical Residuals, Left Knee	5099-5010	10%	
Patellofemoral Syndrome, Right Knee	5099-5024	10%	
COMBINED w/ BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150109, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160018786 (PD201500032)

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