RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01032
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E2, Basic Trainee, medically separated for “chronic right knee instability,” with a disability rating of 20%.  

CI CONTENTION:  “The injury that occurred still hinders everyday life.”  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 - 20070420	VARD - 20080407	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic R Knee Instability	5257	20%	Residuals of R Knee ACL w/ Instability	5257	10%	20070927	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Right Knee Instability.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his right knee after jumping off of a wall and twisting his knee on began in November 2006 during the first week of Basic Training.  Radiographic (X-ray) studies were essentially normal.  Magnetic resonance imaging (MRI) studies showed an anterior cruciate ligament (ACL, a ligament that provides stability to the knee) deficiency.  Surgery was recommended, but the CI declined.  He opted to go through the MEB process instead and pursue surgery outside of the military.  The MEB forwarded “right anterior cruciate ligament deficient knee” for PEB adjudication.  At the time of the Physical Therapy clinic appointment on 12 January 2007, for the MEB NARSUM examination, the CI reported minimal pain at rest and transferred from supine to sitting to standing without apparent pain (blank facial expression).  On examination, the CI was able to fully squat, but with increased pain.  The range of motion (ROM) measurements showed flexion of 125 degrees (normal 140) and extension of 0 degrees (normal).  

The MEB NARSUM examination on 4 February 2004, 3 months prior to separation, the CI reported intermittent episodes of increasing pain associated with twisting type motions.  His symptoms were improved by activity modification and the use a knee brace.  The examination noted a mild effusion, full ROM, and an absence of joint line tenderness (associated with an injury of a meniscus, an internal cartilage cushion.  This was not noted on the MRI though).  He did have a positive pivot shift with a 2+ Lachman, consistent with the ACL injury and indicative of instability. No comment was made on his gait.  It was noted that the impact on activities of daily living were minimal although the impact on duty was significant.  

At the 27 September 2007 VA Compensation and Pension (C&P) evaluation, performed, 5 months after separation, the CI reported constant pain aggravated by walking or standing.  The CI stated that the knee gave way while walking on average four to five times a day.  He was able to walk and do yard work albeit with pain.  It was not recorded if he still used a brace.  The physical examination showed an antalgic (abnormal due to pain) gait, tenderness, and limited flexion at 124 degrees.  Extension was normal.  The CI was able to squat.  Signs of meniscal irritation were negative; side to side laxity (instability) was present, but no comment was made regarding anterior-posterior laxity which is associated with an ACL deficiency.  Minimal arthritis was noted on X-ray.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 20%, coded 5257 (knee, other impairment), citing unstable for final adjudication pending future surgery and rated the knee IAW DoDI 1332.39 which is now rescinded.  The VA rated the right knee condition 10%, also coded 5257, citing recurrent subluxation or lateral instability of the knee which is slight.  This rating was upheld on subsequent VA adjudications.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The evidence does support a 10% rating under the 5257 code (knee, other impairment of; recurrent subluxation or lateral instability), the Board considered the use of knee brace and other consequences of instability, and also noted the objective examination findings by all examiners of right knee instability that were slight.  The Board agreed that this evidence most accurately described “slight” instability under the 5257 code.  

There was evidence of painful motion with functional loss.  The Board members considered if this supported a 10% rating based on §4.59, §4.40 and §4.45.  X-rays were initially normal after the injury, within 6 months of separation, but showed arthritis 5 months after separation.  It was noted to be minimal, though.  The Board concluded that dual coding was not reasonable in this case and that the symptoms and evidence of painful motion were attributable to the underlying unfitting instability.  This would support a rating of no more than 10% for (painful motion), coded 5099-5003.  This, combined with a 10% rating for knee instability coded 5257, would support a combined rating of 20% for the right knee condition.  This provided no advantage to the CI as the PEB adjudicated the condition at 20%.  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 right knee condition.  

BOARD FINDINGS:  In the matter of the right knee 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 20150601, w/attachments
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

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001075 (PD-2015-01032)

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