RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01136
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041022

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, 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 upon a 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 - 20040707	VARD - 20050523	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	0%	Left Knee Shrapnel Wound with Lateral Femoral
Condyle Defect and loss of Motion	5260	10%	20050407	
			Tender Left Knee Scar, Residual of Shrapnel Wound	7804	10%		
Bilateral Hallux Valgus	Not Unfitting 	Bilateral Pes Planus and Hallux Valgus	5267-5280	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in September 2003 after receiving a shrapnel wound from an improvised explosive device (IED) in Iraq.  He sustained a non-displaced fracture of the lateral femoral condyle.  He underwent incision and drainage with debridement of the wound and then was immobilized for the fracture.  Following this he had severely limited range of motion (ROM).  Magnetic resonance imaging (MRI) studies on 23 December 2003 demonstrated a bony defect of the femoral condyle that extended to the joint surface, but did not appear to disrupt it and “minimal joint effusion” with intact menisci, cruciate ligaments, and collateral ligaments.  The left knee pain persisted and the CI underwent manipulation under anesthesia to improve the ROM on 26 January 2004.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left knee shrapnel wound, status post surgical repair with left knee chondromalacia” for PEB adjudication.  

The Orthopedic MEB consult on 23 March 2004 noted the shrapnel injury “took a chunk out of the distal femur” as well as injuring the iliotibial band and quadriceps tendon.  Stateside evaluation noted that the quadriceps function was intact but the CI had very limited ROM.  Following the manipulation of the knee in January 2004, the MEB orthopedic examiner indicated the CI did well, but continued with some limitation of motion, retropatellar pain, grinding, and swelling with impact activities.  The physical examination showed well healed scars.  There was a minimal effusion.  Knee ROM was 125 degrees of flexion (normal 140).  He was neurologically and vascularly intact, with “good” quadriceps muscle strength, but decreased muscle mass/tone (atrophy) on the left compared to the right.  Left knee X-rays showed healing of the fracture, but with a residual defect of the femoral condyle, just above the articular surface.  The MEB orthopedic consult recommended that he CI pursue a lifetime of low impact activities to decrease progression to severe arthritis of the left knee.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 11 May 2004, 6 months prior to separation, the CI reported only that his left knee condition would impact the rest of his life.  The physical examination of the left knee showed a healed scar with mild effusion.  There was no patellar tenderness or crepitus and no evidence of instability.  There was decreased strength with resisted flexion and extension and the CI could not execute deep knee bends. Reflexes were normal and there was localized decreased sensation lateral to the patella.  

The MEB NARSUM examination on 20 May 2004, 6 months prior to separation, noted complaints of a decreased mobility and strength, with grinding knee pain, and swelling with impact activities.  Physical examination showed a normal gait, but the CI reported a sense of “imbalance” when walking.  There was an effusion noted.  The remainder of the examination noted the same findings as summarized in the above MEB examination.  

At the 7 April 2005 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported left knee pain on a daily basis aggravated by going up and down stairs and that he could walk approximately 2 miles or run 1-1/2 miles before “needing a rest.”  He was employed as a police officer and reported he has missed no work because of the left knee.  The physical examination showed a normal gait and posture.  There was a knee effusion and a scar across the patella that was adherent and tender in some areas.  There was a depression noted with an approximate one inch round loss of quadriceps muscle.  Left knee ROM was 90 degrees flexion (normal 140) and 0 degrees extension (normal) with “10 percent” loss of motion on repetition.  Left knee X-rays showed a bony defect of the femur.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee pain 0%, coded 5003 (Arthritis, degenerative (hypertrophic or osteoarthritis)), citing lack of ligamentous laxity and near-full ROM.  The VA rated the left knee pain 10% coded 5260 (Leg, limitation of flexion of), based on the VA C&P examination 5 months after separation, citing the effects of shrapnel wound pain on use of the left knee.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The Board reviewed to see if a higher rating was available with any applicable §4.71a code.  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), to support a rating under the respective codes. There was evidence of a femur fracture which healed with a residual bony defect proximal to the joint and a persistent joint effusion for consideration of coding analogous to knee impairment related to fracture of the femur with malunion (5255).  The rating criteria of 5255 are subjective with 10% for “slight,” 20% for “moderate,” or 30% for “severe” knee disability.  The Board agreed that the disability was best characterized as “moderate” and not “slight” based upon the persistent bony defect and effusion noted at all examinations, with significant knee pain and increased swelling with daily activities such as stairs.  All members agreed that it was not “severe,” based on the CI’s normal gait and the CI reported that the condition did not interfere with his performance as a police officer after separation.  There was no higher rating available coding IAW VASRD §4.71a and the Board considered if coding and rating the CI’s injury as a muscle injury IAW VASRD §4.73 (muscle injuries) resulted in a higher rating.  Coding the knee disability as 5314 for muscle group XIV (quadriceps muscles) injury also has subjective rating criteria, with 0% rating for “slight,” 10% rating for “moderate,”30% rating for “moderately severe,” and 40% rating for “severe” muscle injury.  All Board members agreed that the CI’s injury which included some localized loss of quadriceps muscle substance and loss of muscle mass, with a normal gait could not be classified as “severe” (or even “moderately severe”) muscle injury according to VASRD §4.56 (Evaluation of muscle disabilities) for a rating as high or higher than arrived at above and this approach was abandoned.  There was therefore no higher rating than 20% available with any applicable VASRD code.  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 left knee pain, coded 5299-5255.  

Contended PEB Condition:  Bilateral Hallux Valgus.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left knee pain, the Board unanimously recommends a disability rating of 20%, coded 5299-5255 IAW VASRD §4.71a. In the matter of the contended bilateral hallux valgus condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	5299-5255	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150623, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB								

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170002612   (PD201501136)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA