RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00589
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060611

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Chemical Operations Specialist, medically separated for “left knee injury,” with a disability rating of 20%.

CI CONTENTION:  The CI contends his left knee has worsened.   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 - 20060418	VARD - 20070808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left ACL Insufficiency S/P ACL Reconstruction	5257	20%	S/P Lateral and Medical Meniscus Tears, Left Knee	5299-5260	10%	20070723	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Left ACL (Anterior Cruciate Ligament) Insufficiency S/P ACL Reconstruction.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in October 2000 while playing collegiate football prior to his enlistment in the Army.  He had an arthroscopically assisted repair using an autologous patellar tendon graft. In September 2005, while playing unit football he twisted his left knee and was treated for a ligamentous injury with ice, elevation, no weight bearing and Ultracet (tramadol, an opioid-like medication and acetaminophen, a pain reliever).  Magnetic resonance imaging (MRI) dated 20 September 2005 demonstrated post-surgical changes of an anterior cruciate ligament repair with the repaired ligament appearing intact.  Additionally, there were tears of the anterior horn of the lateral meniscus and posterior horn of the medial meniscus and a small knee joint effusion.  Physical therapy evaluation on 21 October 2005 noted hyperextension/rotation as the method of injury.  Strengthening exercises were reviewed.  Orthopedic evaluations in November 2005 and December 2005 demonstrated left knee KT 2000  testing (to determine laxity endpoint) of 7mm and 5 mm respectively and left knee positive McMurray testing medially and laterally (to determine meniscal tears).  On 5 December 2005 the CI declined left knee arthroscopy.  Despite treatment, the left knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded medial meniscus tear, left knee and lateral meniscus tear, left knee, for PEB adjudication. 

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 24 January 2006, 5 months prior to separation, the CI reported “tore ACL-2002/ligament damage to knee 2005.”  The examiner noted “left knee 5-110 degrees” and recorded left knee meniscal tears, lateral and medial in the summary of defects and diagnoses.  The MEB NARSUM examination on 26 January 2006, 5 months prior to separation, noted complaints of pain in the left knee. Physical examination revealed an asymmetric knee range of motion with the left knee ranging between 5 and 110 degrees of flexion with medial and lateral joint line tenderness.  Orthopedic examination on 14 April 2006 revealed a full active range of motion (ROM), medial and lateral joint line tenderness without erythema (redness), a grade 2 Lachman (to determine laxity) with endpoint (KT 2000 ACL left knee 11 mm), and positive McMurray tests medial and lateral joint lines.  The examiner noted the left knee ACL graft was stretched by physical examination, but the graft was intact according to the MRI report.  

At the 23 July 2007 VA Compensation and Pension (C&P) evaluation, performed 13 months after separation, the CI reported that he had intermittent pain the left knee at a level of 4-5/10 (10 being the worst pain), which hurt after he had been on his feet all day or if he tried to run.  There was stiffness in the morning, which improved as the day progressed. He denied heat or redness, instability, locking, or lack of endurance.  Flare-ups occurred 1-2 times a month with pain to 8/10, which lasted a few hours. Examination revealed a flexion ROM of 0-115 degrees with limitation due to pain.  There was pain in the left knee upon palpation of the inferomedial and inferolateral borders and less than 5 mm of motion with the anterior and posterior drawer tests.  McMurray’s testing was negative.  The range of motion (ROM) examinations 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)	PT ~5 Mos. Pre-Sep
	MEB ~3 Mos. Pre-Sep
	VA C&P ~13 Mos. Post-Sep
	
Flexion (140 Normal)	115	110	115	
Extension (0 Normal)	0	5	0	
Comment	Painful motion	Medial and lateral joint line tenderness 	Painful motion, no instability, negative McMurray testing	
§4.71a Rating	10%	0% (PEB 20%)	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5257 code (Knee, other impairment), citing chronic left ACL insufficiency status post ACL reconstruction with follow on injury, and 2A Lachman with end point.  The VA assigned a 10% rating using an analogous 5299-5260 code (Leg, limitation of flexion), based on the VA C&P examination 13 months after separation, citing painful limitation of motion.  Board members noted after a discussion that the PEB rating was related to chronic left ACL insufficiency based on an orthopedic examination prior to separation, which demonstrated ligamentous laxity of moderate severity without mention of the torn non-dislocated menisci of the left knee for which the CI did not undergo surgery (5258, 5259).  There was no evidence of severe subluxation or lateral instability to support a 30% rating under the 5257 code (knee, other impairment of) nor was there a significant limitation of motion (5260, 5261) to warrant a compensable rating.  However, there was painful motion on the physical therapy examination 5 months prior to separation, which was referred to by the NARSUM examiner, although painful motion was not explicitly noted on the NARSUM examination.  The VA examination, although remote, did note painful motion.  A VA Counsel General opinion dated 1 July 1997 permits instability (5257) to be combined with arthritis (5003) is not considered pyramiding IAW VASRD §4.14.  After a discussion Board members considered the CI’s painful knee motion, evidenced by positive McMurray’s testing as well as prior and subsequent examinations, with a noncompensable ROM to warrant an additional rating of 10% using code 5099-5003 to be reasonable and appropriate.  Finally, 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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic left ACL insufficiency condition, coded 5257 and a disability rating of 10% using code 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic ACL insufficiency S/P ACL reconstruction condition, the Board unanimously recommends a disability rating of 20%, coded 5257 IAW VASRD §4.71a and a disability ration of 10%, coded 5099-5003 IAW VASRD §4.71a.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic ACL Insufficiency S/P ACL Reconstruction	5257	20%	
	5099-5003	10%	
COMBINED	30%	

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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170000685 (PD201500589)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA