RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00447
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Bradley Fighting Vehicle Systems Maintainer, medically separated for “chronic right knee pain” with a disability rating of 10%.

CI CONTENTION:  “Please review 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 confined to 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 - 20090305	VARD - 20130730	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5099-5003	10%	Right Knee Condition	5260	NSC	STR	
Lumbago	Not Unfitting	Low Back Condition	5237	NSC	STR	
Myopia	Not Unfitting	No VA Placement	
Tooth Pain	Not Unfitting	No VA Placement	
Esophageal Reflux	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:

Chronic Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s knee pain began after a motocross accident.  The CI was diagnosed with a ruptured right patellar tendon and possible anterior cruciate ligament (ACL) injury.  He underwent right patellar tendon repair surgery in March 2008.  Physical therapy did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “internal derangement of the right knee” for PEB adjudication.  Diagnostic imaging (MRI) on 19 October 2008 showed a torn ACL and posterior horn of the lateral meniscus.
During an orthopedic examination on 22 October 2008 (7 months pre-separation), the physical examination showed flexion to 135 degrees (normal 140) and extension to 15 degrees (normal 0); painful motion was not addressed.  There was evidence of instability due to ACL injury (1+ Lachman test with soft endpoint).  There was evidence of thigh muscle atrophy.  The orthopedic surgeon examiner opined that the limitation to extension and marked quadriceps asymmetry may have contributed to the CI’s instability symptoms, but the examination was not completely convincing of an ACL tear.  The examiner recommended surgery for a more specific diagnosis, but the CI was not interested [in a second knee surgery] at that time.

At a physical therapy appointment on 8 December 2008 (6 months pre-separation), the CI reported incomplete extension with pain during squatting.  Physical examination showed thigh muscle atrophy and weakness (4+/5) with extension.  Instability testing was not addressed.  ROM was flexion to 132 degrees and extension to 2 degrees with painful motion.

The L3 physical profile dated 09 December 2008 documented chronic right knee pain and instability (torn ACL and s/p patellar tendon repair).  The CI was only allowed to run during physical therapy or per therapist exercise program.  The CI was not allowed to participate in jumping or cutting activities and had to wear a hinged knee brace when working on/moving over uneven terrain (commonly known medical recommendations to guard against knee instability).

During the MEB NARSUM examination on 9 December 2008 (6 months pre-separation), the CI reported swelling after excessive motion and patellar tendon pain that made it difficult to kneel and perform maintenance operations.  He reported his knee giving way several times a day when walking normally and over uneven ground or slopped surfaces.  The CI denied increasing pain, fatigue, weakness, incoordination, or lack of endurance with repeated exercise.  Physical examination showed a non-antalgic gait with no swelling or effusion.  There was tenderness to palpation of the patellar tendon, tibial tuberosity, and medial femoral condyle; and muscle atrophy with weakness (4+/5) on flexion and extension.  ROM was flexion 120 degrees and extension 10 degrees with painful motion.  There was evidence of instability due to ACL injury (1+ Lachman test).  The examiner stated the CI continued to have right knee instability and pain which prevented successful performance of his MOS and some common soldier tasks.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded 5099-5003 (degenerative arthritis).  The VA did not service connect the right knee condition, coded 5260 (leg, limitation of flexion), citing the CI failed to report to his VA examination and medical evidence failed to show that this disability had been clinically diagnosed.  The Board agreed there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion; however, there was limitation of motion which supported a rating under the diagnostic code for limitation of extension (5261) to support a 10% rating; corroborated by the orthopedic and MEB NARSUM examinations proximate to separation.  The Board considered a 10% rating for limitation of flexion based on painful motion with functional loss, but this would be considered pyramiding §4.14 since the limitation of extension already includes painful motion. 

The Board agreed that the physical profile, and orthopedic and MEB NARSUM examinations proximate to separation demonstrated the presence of ligamentous instability (5257) to support a 10% rating.  Both examiners specifically diagnosed knee instability; and, the MEB NARSUM examiner stated the CI had right knee instability and pain which prevented successful performance of his MOS and some common soldier tasks.  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 higher 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).  No additional functional limitation was evidenced by the examinations.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends disability 10% rating for right knee extension coded 5261; and 10% rating for right knee instability, coded 5257.

Contended PEB Conditions:  Lumbago, Myopia, Tooth Pain, or Esophageal Reflux.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of these conditions were profiled or implicated in the commander’s statement and none were judged to fail retention standards.  There was no performance-based evidence from the record that any of these conditions 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 any of these contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic right knee pain condition, the Board unanimously recommends disability ratings of 10% coded 5261, and 10% coded 5257 IAW VASRD §4.71a.  In the matter of the contended lumbago, myopia, tooth pain and esophageal reflux, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 Limitation of Extension	5261	10%	
Right Knee Instability, Anterior Cruciate Ligament Tear	5257	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, 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

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000106 (PD201500447)

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