RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00579
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20060717

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Cannon Crewmember, medically separated for “chronic left knee pain associated with osteoarthritis,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 - 20060601	VARD - 20070207	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain…	5261	10%	Left Knee DJD w/Post-Operative Scar	5010-5260	10%	20061108	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain Secondary to Osteoarthritis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI originally injured his left knee in 1984.  He underwent surgery and made a full recovery and did not require a medical waiver to enter military service.  After re-injuring his left knee in 1999, he was noted to have anterior cruciate ligament (ACL) laxity and osteoarthritis.  He underwent arthroscopy and ACL shrinkage surgery and possible medial meniscus (an internal cartilage cushion) debridement with good results.  He was able to perform all of his duties to include a deployment, although he did have some recurrent pain in 2000.  In 2005 he again noted pain, locking and catching in his left knee.  An MRI on 29 November 2005 showed a normal medial meniscus and a torn lateral meniscus with a portion missing consistent with the prior surgery (although a medial meniscus had been noted in the record).  Arthritis and a loose body were also present.  This lead to a repeat arthroscopy on 20 December 2005.  The surgery revealed grade 4 chondromalacia of the lateral patellar facet, patellar instability and multiple loose bodies.  The latter were removed which resolved his catching and locking.  The menisci were normal.  Despite the surgery, his pain remained.  On 8 February 2006 he underwent a Fulkerson osteotomy of his proximal tibia and proximal patellar realignment and elevation with lateral release.  Post-operatively his pain persisted and he had continued diminished range of motion.  A follow up X-ray showed expected post-operative changes and early degenerative changes.  Despite rehabilitation, his condition did not improve sufficiently to allow unrestricted duty.  The MEB forwarded “chronic pain, associated with osteoarthritis, left knee” for PEB adjudication.  The range of motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Knee ROM
(Degrees)	NARSUM ~3 Mos. Pre-Sep	VA Ortho – 2 Mos. Post-Sep.	VA C&P – 4 Mos. Post-Sep	
Flexion (140 Normal)	90	105	110	
Extension (0 Normal)	10	0 (full)	0	
Comment	Tenderness.  Two months post op	Minimal limp.  No instability.  Painful gait.  Quad atrophy.	Gait slow but normal.  Stable knee without meniscal signs.  Atrophy not noted.	
§4.71a Rating	10%	10%	10%	

The MEB NARSUM, dated 27 April 2006, 2 months after surgery, noted that the CI presented using a cane for ambulation and complained of persistent pain.  The examiner observed that the CI had tenderness over the surgical screws as well as over the proximal tibia and the lateral facets of his left patella.  His ROM was limited (see chart above).  

At the Compensation and Pension (C&P) evaluation, performed on 8 November 2006, 4 months after separation, the CI reported intermittent flare ups of pain related to weather or activity.  He reported no locking but occasional bucking of his left knee and some popping during activity.  He was taking no medications for his knee pain.  The physical examination showed a slow but normal gait without use of any assistive devices.  The examiner noted tenderness to palpation along the medial joint line and mild crepitus.  The ROM is charted above.  There was no evidence of weakness with resistance or loss of ROM with repetition.  Testing for instability was negative.  The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5261 (leg, limitation of extension of), citing painful motion.  The PEB stated that the condition did exist prior to service (EPTS), but did not deduct anything from the rating.  The Board observed that the ROM values used by the PEB were taken 2 months after surgery and that the examination of the left knee steadily improved over time.  The VA also rated the left knee condition 10%, coded analogously as 5010-5260 (traumatic arthritis of the leg and limitation of flexion), citing painful motion.  

The limitation of motion recorded in orthopedics and by the VA examiner, both examinations are further from surgery that the PEB evaluation, do not support a compensable rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss which supports a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and the arthroscopy in December 2005 noted that the menisci were intact.  Ratings using either 5258 (a history of dislocated meniscus or loose body causing frequent locking with recurrent effusions) or 5259 (history of surgery to remove a meniscus) were not supported.  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).  Accordingly, no route to a rating higher than the 10% adjudicated by the PEB was found.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the “chronic left knee pain” condition.  

BOARD FINDINGS:  In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, 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, AR20160018766 (PD201500579)

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