RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00511
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061207

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “chronic pain/instability,” with a disability rating of 10%.  

CI CONTENTION:  “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 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 - 20060928	VARD - 20070316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain/Instability, S/P Revision ACL Reconstruction	5257	10%	Postoperative Residuals, Left Knee Injuries	5257	10%	20070313	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Pain/Instability (Left Knee).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left knee in April 1996 (during a prior term of service in the Navy) and required anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction at that time.  He reinjured his left knee when he fell while running in April 2005, and underwent a left knee ACL reconstruction, debridement of a medial meniscal tear and repair of a full-thickness cartilage defect in October 2005.  Pre-operative radiographic imaging reported mild degenerative joint disease.  Following surgery in 2005 further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left knee instability” for PEB adjudication.  

At an orthopedic follow-up on 7 June 2006 (6 months prior to separation), the CI reported left knee pain graded 0-3/10 in severity, although in another part of the history the examiner wrote “no pain.”  Examination showed some tenderness over the surgical hardware, but was silent regarding painful motion.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 16 June 2006, 6 months prior to separation, the CI complained of constant pain and instability of the left knee, but in another section of the report “intermittent pain with prolonged standing and walking” was described.  The physical examination showed left knee tenderness, swelling, and laxity, but no limitation of movement.  Painful motion was not mentioned.  The type and degree of laxity was not described.  A re-evaluation by orthopedics on 18 August 2006, 4 months prior to separation, the CI reported 5/10 pain of the left knee.  Pain was worse while walking, running or jumping, and was improved by rest.  Examination showed crepitus of the kneecap, but there was no mention of painful motion.  

At the MEB NARSUM examination on 29 August 2006, 4 months prior to separation, the CI reported that the left knee instability improved after surgery, but he still experienced difficulty walking on downhill surfaces and used a knee brace for stability.  “Significant” pain associated with activities was denied.  He could not run but could walk, bike and swim.  The physical examination showed left thigh muscle atrophy due to decreased knee use.  Left knee swelling and tenderness were absent, and painful motion was not mentioned; but minimal crepitus was present.  Left knee flexion was 130 degrees (normal 140 degrees) and extension was 0 degrees (normal 0 degrees).  Tests for collateral ligaments and the ACL were normal, but there was mild laxity of the PCL.  The examiner specified the PCL as the cause of instability symptoms and profiling restrictions, and stated that revision surgery of this ligament was not warranted due to the unpredictability of improvement.  The examiner also noted that outpatient entries consistently indicated a “low report of pain” except for one recent visit that described 5/10 pain.

At the 13 March 2007 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported permanent instability, pain and swelling in his left knee.  He did not currently wear a knee brace but did take anti-inflammatory medication, which was moderately helpful for pain.  Since January 2007, the month after separation, he was engaged in an occupation as a truck driver, and lifted and installed heavy equipment in oil fields.  The physical examination showed a normal gait.  There were well-healed scars of the left knee, and swelling and tenderness were absent.  Left knee flexion was 140 degrees and extension was 0 degrees. The CI could “squat and arise without apparent discomfort.”  A test for possible meniscal injury was negative and tests for ACL and PCL ligament instability were positive, although the degree of instability was not described.  There was no additional limitation after repetitive motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10% for “slight” disability, coded 5257 (knee, other impairment of).  The VA also rated the left knee condition 10% under the same code, based on the VA C&P examination approximately 3 months after separation, citing instability, weakness and ligament laxity.  Board members agreed that evidence of knee instability was best described as “slight” and therefore the next higher 20% rating via the 5257 coding pathway was not warranted. Although there was no route to any rating via 5260 or 5261 codes (limitation of motion), 5258 code (dislocated meniscus or loose body causing frequent locking), or 5255 or 5262 codes (long bone conditions), the Board debated if dual coding was appropriate in this case.  The CI reported the presence of knee pain, and an additional 10% rating in this circumstance could be considered IAW VASRD §4.40 (functional loss), §4.59 (painful motion) or the 5259 code (cartilage, semilunar, removal of, symptomatic).  Although the reported presence and severity of knee pain was variable, the application of VASRD §4.40, §4.59 or DC 5259 in this case was reasonably conceded, and was consistent with the PEB’s “chronic pain” language.  The Board noted the NARSUM examination finding of thigh muscle disuse atrophy in this regard, since the mild knee instability was not likely a sole explanation for this finding.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separation rating of 10% for left knee instability, coded 5257, and 10% for symptomatic cartilage removal, coded 5259, for a combined rating of 20% for the left knee condition.  

BOARD FINDINGS:  In the matter of the chronic pain and instability of the left knee condition, the Board unanimously recommends a disability rating of 10% coded 5257, and 10% coded 5259, for a combined 20% rating 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 to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Instability Left Knee	5257	10%	
Chronic Pain Left Knee	5259	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150529, 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, AR20170002162 (PD201500511)

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