RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01394
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040109

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

CI CONTENTION:  The CI’s condition conditions to worsen and negatively impact daily activities.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20031023	VARD – 20040209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain…	5099-5003	0%	Retropatellar Pain Syndrome, Right Knee	5299-5260	0%	20031030	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began during the end of basic training, when she experienced intermittent swelling after physical exercises.  At an emergency room visit dated 7 January 2002, the record indicated the CI fell and hit her leg against a rail causing a contusion/sprain of the left lower leg and foot, although later notes indicated she twisted her right knee.  On 1 November 2002 the CI complained of right knee pain for 12 months.  She had a history of patella (knee cap) dislocation as an adolescent and was diagnosed with patellofemoral syndrome/patellar subluxation with full range of motion (ROM) of the right knee.  
At an orthopedic visit dated 20 December 2002, the CI complained of right knee pain for 2 years, which increased with activity in January 2002 when she twisted her knee.  On examination she had tenderness to palpation at the medial plica (a fold of synovial membrane most commonly in the anteromedial aspect of the knee) with mild tenderness to palpation at the medial collateral ligament.  There was a full ROM with no laxity (negative Lachman/drawer tests), no meniscal tear (negative McMurray’s test), and no varus/valgus strain.  A steroid injection was given and the CI was referred for physical therapy.  At a physical therapy evaluation in January 2003 the CI denied locking/catching of the knee, but it gave way about monthly.  S he denied instability.  On examination there was no edema of the knee; her gait was within normal limits; the active ROM was within normal limits; and muscle strength was 5/5.  She had pain with palpation in the medial patellar margin and substantial pain with direct pressure to the medial femoral condyle.  There was no laxity, but valgus testing was very painful. The patella grind and plica tests were negative.  Magnetic resonance imaging (MRI) dated 8 March 2003 demonstrated no evidence of internal derangement.  There was minor fissuring of the medial patellar facet cartilage (inflammation and deterioration of cartilage) and changes consistent with the iliotibial band syndrome were identified.  In April 2003 an orthopedic surgeon’s assessment was right knee pain with patellar chondromalacia.  Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)) was prescribed along with continued physical therapy.  Orthopedic evaluation on 1 July 2003 noted pain under the right patella and tenderness along the medial joint line, which was assessed as patellofemoral syndrome.  

During the 23 July 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported bursitis in the right knee and some arthritic symptoms and right knee pain along with difficulty standing or sitting for lengthy periods of time.  She also noted swelling around the knee joint and the right knee gave out.  The examiner listed right knee recurrent dislocation of the right patella in the summary of defects and diagnoses.  

The 19 September 2003 MEB NARSUM examination, 4 months before separation, the CI complained of difficulty driving for prolonged periods or to walk moderately long distances as well as difficulty negotiating stairs and performing the Army physical fitness test.  Physical examination showed no effusion.  There was positive apprehension (to determine the patellofemoral syndrome) of 1-2+ on the right knee.  There was no laxity or increased mobility of the patella and there was no indication of instability (Lachman’s test negative), a meniscal tear (McMurray’s test negative), or lateral collateral or medial collateral ligament laxity.  There was no gross discomfort at the iliotibial band and no indication of instability or quadriceps atrophy. The strength on the right leg was 4/5, felt to be secondary to retropatellar pain according to the CI.  On examination the right knee ROM was 130 degrees flexion and 0 degrees extension.  ROM measurements of the right knee performed on 29 October 2003 revealed flexion 110 degrees (normal 140) and 0 degrees extension (normal 0), while the left knee flexion was 105 degrees and 0 degrees extension.  There was no loss of motion or painful motion although there was tenderness to palpation to the medial edge of the patella.        

At the 30 October 2003 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported pain climbing up and down stairs and feeling that she could not run.  She also complained of increased pain with weight bearing activities but had no decrease in ROM.  Physical examination showed a normal gait.  There was a negative Lachman’s sign.  Musculoskeletal strength was 5/5.  The CI was able to bear all her weight on one foot and was able to walk on her heels and tandem walk.  On examination the right knee ROM flexion was 110 degrees and 0 degrees extension.  Following repetitive movement flexion was 112 degrees and extension 0 degrees without pain.  The examiner’s functional assessment noted the CI was able to walk a mile and half on the treadmill, but did complain of pain climbing up and down stairs.  However, the CI felt she could not run and there was increased pain with weight bearing activities, but no decrease in ROM.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5099-5003 (arthritis, degenerative), citing “rated for pain.”  The VA rated the right knee condition 0%, coded 5299-5260 (limitation of flexion of leg), based on the VA C&P examination 2 months before separation, citing leg flexion limited to 60 degrees.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 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), to support a rating under the respective codes.  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).  No additional functional limitation was evidenced by the examinations.  Therefore the panel concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee pain condition.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150614, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007470, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure