RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00492
BRANCH OF SERVICE: Army	SEPARATION DATE:  20080916

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Health Care Specialist, medically separated for “knee, other impairment, left” with a disability rating of 20%.   

CI CONTENTION:  The CI contends for all of his 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 - 20080715	VARD - 20150820	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Knee, Other Impairment, L	5237	20%	Left Knee Injury/Condition	5260	Deferred	STRs	
Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	Deferred	STRs	
		Tinnitus	6260	10%	STRs	
Abnormal EKG	Not Unfitting	No VA Entry				
Flat Foot	Not Unfitting	Bilateral Pes Planus	5276	Deferred	STRs	
Elevated Blood Pressure	Not Unfitting	No VA Entry				
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Knee, Other Impairment, Left.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in February 2006 following a hyperextension injury.  An MRI showed a tear of the anterior cruciate ligament (ACL) which provides stability to the knee.  This was repaired surgically and the CI did well until he reinjured it leading to a second repair in October 2007.  He again did well following surgery until a third tear of the ACL in March 2008.  The CI elected MEB rather than a third operation.  Meniscal impairment was not documented.  A CT scan on 28 March 2008 showed mild degenerative changes of the joint.  An MRI on 25 April 2008 documented a possible re-tear of the ACL and a tear of the posterior cruciate ligament (PCL) as well as degeneration of the kneecap cartilage (chondromalacia patella).  The MEB forwarded left knee repeat tear of the ACL for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 30 April 2008, the CI was noted to have reduced range of motion (ROM), instability, crepitus, and pain.  Formal ROM testing in physical therapy on 9 May 2008 showed normal extension (0 degrees), but flexion limited to 35 degrees (140 is normal).  The knee was stable, but guarding was present.  The examiner commented that the patient was “anxious to know what is a ‘normal’ result for this med board exam.  Non-antalgic gait noted.”  The MEB NARSUM examination was dated 20 May 2008, 11 days later and 4 months prior to separation.  It was accomplished by an orthopedic surgery resident.  The examination and findings were reviewed and confirmed by a second (staff) orthopedist.  The CI reported subjective instability, but “giving way” was not recorded.  On examination, the CI was noted to have flexion to 120 degrees (passively), but with pain beyond 90 degrees with active motion.  Instability of the ACL was present.  The gait was non-antalgic (an antalgic gait is a gait abnormal due to pain).  The use of a brace or assistive device was not recorded.    

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition at 20%, coded 5237 (lumbosacral or cervical strain).  The Board noted that 5237 is a back code.  The PEB noted instability and painful motion.  The code 5257 is for instability of the knee and was most likely the code intended by the PEB.  The PEB rated the CI IAW DoDI 1332.39, since rescinded.  The VA deferred a rating pending an examination.  The ROM limitation cited by physical therapy was significantly different that that measured in orthopedics 11 days later.  The Board noted that the CI specifically asked what was normal for this examination as recorded by the examiner.  This examination was 11 days closer to the third injury and more remote from separation.  The evaluation for the MEB NARSUM was accomplished by an orthopedic surgeon and confirmed by a second, more experienced orthopedist the same day.  This examination is also more consistent with the non-antalgic gait recorded by both the physical therapist and at the orthopedic appointment.  Painful and limited motion was present as was instability.  An abnormal gait was not recorded.  Signs of meniscal irritation were not recorded.  Some degenerative changes were present.  A 10% rating is supported under the code 5003 for limited and painful motion with X-ray evidence of arthritis.  The instability also supports a rating under the code 5257.  The Board considered if the evidence supported a slight (10%) or moderate (20%) impairment.  It noted that the gait was recorded as non-antalgic implying a normal or near normal gait.  The use of a brace was not recorded.  The totality of evidence supports a slight rather than moderate impairment.  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 left knee chondromalacia patella and degenerative joint disease coded 5003 and 10% for left knee ACL instability coded 5257.  However, as this would be of no benefit to the CI, the Board recommends no change to the original rating.

Contended PEB Conditions:  Hearing Loss, Abnormal EKG, Flat Foot, and Elevated Blood Pressure.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement.  All were judged to meet retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS: In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hearing loss, abnormal EKG, flat foot, and elevated blood pressure conditions, 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 following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, 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 
XXXXXXXXXXXXXXXXXX, AR20170002158 (PD201500492)

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 accept the Board’s recommendation and hereby deny the individual’s application. 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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA