RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00811
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030318

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

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 - 20021202	VARD - 20030324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain…	5099-5003	0%	Post-Operative Residuals, Patellofemoral Syndrome, Left Knee	5262-5019	10%	20021016	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition, which was first noted in February 2000, developed gradually without trauma.  Physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and Tylenol #3 (codeine, a narcotic and acetaminophen, a pain reliever) afforded no significant relief.  The CI underwent a left knee video arthroscopy and open lateral retinacular release on 19 October 2000.  On 22 November 2000, the CI reported she fell down approximately eight stairs, injured her left knee and redeveloped knee pain, although the examiner noted there was no evidence of significant internal derangement; however, she noted occasional giving way.  At a subsequent visit she noted stairs were “excruciating.”  In October 2001 the CI received a steroid injection to the left knee.  Examination in December 2001 revealed left knee tenderness especially medially with flexion and a slight grating beneath the patella, which was also painful.  X-rays on 3 December 2001 showed no bony changes in the knee and patella and joint spaces were not narrowed.  A note in January 2002 indicated the CI had initial relief from the first hyperosmolar injection and underwent a second injection on 2 January 2002.  In March 2002 the CI received additional hyperosmolar trigger point injections with improvement of the chronic left knee pain.  Trigger point injections were given twice in August 2002 for chronic myofascial knee pain.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left knee pain secondary to chronic sprain” for PEB adjudication.  

The MEB NARSUM examination on 27 August 2002, approximately 7 months prior to separation, noted complaints of both sharp and dull knee pain dependent on the CI’s level of activity.  The pain was exacerbated by going upstairs, running, jumping, sit-ups, lifting, brisk walking and marching.  Physical examination revealed diffuse tenderness to palpation throughout the entire left knee, most significantly on the medial joint line.  She also had tenderness to palpation along the tibial and femoral medial condylar areas known as flares.  Pain was reproduced with varus stress of the left knee, although it appeared stable to varus and valgus stress.  There was no instability or evidence of a meniscal tear (negative McMurray’s test).  Range of motion (ROM) was 0 degrees extension and 130 degrees flexion.  Neurological evaluation was unremarkable.  At the MEB examination recorded on DD Forms 2807-1 and 2808 dated 2 September 2002 and 18 September 2002 respectively, approximately 6 months prior to separation, the CI reported knee trouble since basic training, had a laparoscopic lateral release, and had been fitted for a brace on numerous occasions.  The examiner noted no effusion of the left knee, but there was minimal sub-patellar crepitus.  There was patellar hypermobility from side to side with pain with full flexion; and there was no instability or evidence of a meniscal tear.  

At the 16 October 2002 VA Compensation and Pension (C&P) evaluation, performed approximately 5 months before separation, the CI reported there were no alleviating factors that made her knee feel better, although trigger point injections decreased the pain from 7/10 (10 being the worst pain) to 4/10.  On examination there was tenderness to palpation along the medial aspect of the joint line of the left knee with a moderate amount of crepitus and a positive patellar compression test.  There was no instability or evidence of a meniscal tear.  The ROM was normal, but there was increased pain on flexion and full extension.

The 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)	MEB ~ 7 Mos. Pre-Sep
	VA C&P ~5 Mos. Pre-Sep
	
Flexion (140 Normal)	130	Normal ROM	
Extension (0 Normal)	0		
Comment	Tender entire knee, mostly on medial joint line; tender along tibial, femoral medial condyle flares; knee pain caused varus stress; however, mechanically stable to varus and valgus stress	Painful motion; tender along medial joint line; moderate crepitus; + patellar compression test; reflexes nml;	
§4.71a Rating	10% (PEB 0%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the left knee pain under an analogous code 5099-5003 (Arthritis, degenerative (hypertrophic or osteoarthritis)), citing the US Army Physical Disability Agency pain policy.  The VA assigned a 10% rating under an analogous 5262-5219 code (Tibia and fibula, impairment of:-Bursitis), based on the C&P examination approximately 5 months before separation, citing painful motion.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  The CI had a lateral retinacular release.  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) and there was no ankylosis (5256).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 the left knee pain condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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 medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain…	5099-5003	10%	

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

AR20170011691, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,	
Enclosure