RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE:  PD-2015-00558
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20050603

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Human Resource Information System Management Specialist, medically separated for “chronic pain of the left knee” with a disability rating of 0%.

CI CONTENTION:  The CI contends he was not evaluated for his back and depression conditions.  The complete application is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20050331	VARD - 20060201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain of the Left Knee…	5099-5003	0%	Chronic Left Patellofemoral Knee Pain	5260	10%	20051026	
Major Depressive Disorder, Single Episode, Mild	Not Unfitting	Adjustment Disorder 	9440	10%	20051110	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an atraumatic onset of left knee pain in early 2003.  Magnetic resonance imaging (MRI) was normal, confirming intact menisci and ligaments and the CI was diagnosed with patellofemoral pain syndrome.  Outpatient STR entries documented normal range of motion (ROM), both observed and measured, and there were no entries to the contrary.  Most entries did not comment on painful motion, but one specified that it was absent and another that it was present.  There was ample STR documentation of the absence of effusion, stability to stress testing, and negative signs of impingement.  Surgery was not indicated and conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The CI was referred for an MEB which in turn forwarded “chronic left patellofemoral knee pain” to the PEB.  

The NARSUM examination on 16 December 2004, 6 months before separation, documented “constant and moderate” pain (specifically excluding subjective instability or locking) that limited “increased or vigorous activity, carrying heavy loads, walking fast, running, climbing upstairs or hills.”  The physical examination recorded tenderness without effusion, 4-plane stability to stress testing, negative signs of impingement, and “full” ROM (no measurements or comment regarding painful motion).

A VA Compensation and Pension (C&P) examination on 26 October 2005, 5 months after separation, documented “daily” but variable (1-10/10) pain aggravated by running, prolonged standing, and negotiating hills or stairs.  The physical examination recorded a normal gait, crepitus and swelling, stability to stress testing, and no impingement.  Measured ROM was flexion to 130 degrees (normal 140) and extension to 0 degrees (normal), with onset of painful motion at 90 degrees noted. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5099-5003 (analogous to degenerative arthritis) cited full ROM and the absence of other ratable criteria, and referenced provisions of VASRD §4.31 (no-percent rating).  The VA‘s 10% rating under code 5260 (limitation of flexion) was based on the C&P evidence and cited painful motion.  There was no minimum compensable ROM limitation, no persistent effusion and locking, and no fracture with non-union or malunion to support a minimum compensable rating under any other code; and, there was no evidence of joint instability for separate rating.  Although the NARSUM did not document painful motion, members deliberated whether it was fairly conceded in this case in support of a minimum compensable 10% rating.  Although painful motion was specified in only one outpatient entry in the service evidence, it was convincingly documented in the C&P examination that was more temporally probative than the NARSUM.  Furthermore the nature of the pathology would logically be associated with painful motion.  Members thus agreed that the VASRD §4.59 criterion of painful motion was sufficiently supported in justification of a 10% rating recommendation.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the left knee condition under code 5024 (tenosynovitis, defaulting to criteria of 5003).

Major Depressive Disorder.  The CI developed depression in service that was treated with an anti-depressant and was situationally exacerbated by MEB developments.  There was no evidence for suicidality, psychiatric admissions, disciplinary issues or other acute features.  A psychiatric consultant to the MEB provided the Axis I diagnosis and opined that the CI “does not have a psychiatric condition that warrants disposition through medical or administrative channels,” and judged it to meet retention standards.  The psychiatric profile remained S1 throughout service, and no mental health condition or impairment was referenced in the commander’s performance statement.  A VA mental disorders C&P examination (contemporary with that above for the knee condition) documented that the CI was employed and planning college, and characterized the psychiatric acuity as “mild.”

The panel’s main charge was to assess the fairness of the PEB’s determination that the depressive disorder was not unfitting.  The MEB psychiatric opinion that the condition met retention standards, the commander’s statement, and the S1 profile were all compelling evidence in support of a conclusion that the mental health condition was not unfitting.  Members agreed that there was no performance-based evidence for any psychiatric impairment that significantly interfered with satisfactory duty performance at separation.  After due deliberation in consideration of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the major depressive disorder.  

BOARD FINDINGS:  In the matter of the left knee condition, the panel unanimously recommends a Service disability rating of 10%, coded 5024 IAW VASRD §4.71a.  In the matter of the contended major depressive disorder, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Patellofemoral Tendonopathy, Left Knee	5024	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160603, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006457, XXXXXXXXXXXXXXXXXX.

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,