RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2015-01440
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040812

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Cavalry Scout, medically separated “chronic left knee pain” with a disability rating of 0%.  

CI CONTENTION:  The CI contended he still suffers from complications of the knee condition.  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 - 20040603	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	No VA Exam in Evidence	
COMBIEND RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic left knee pain condition initially began in May 2002 while playing broomball (played on ice and similar to hockey, but incorporating some soccer strategies).  At an orthopedic clinic visit on 15 August 2002 the CI noted he was still with pain.  Magnetic resonance imagining (MRI) showed a partial PCL (posterior cruciate ligament) tear.  Examination revealed no laxity or evidence of a meniscal tear, although the knee appeared swollen.  The CI was involved in a motor vehicle accident on 9 September 2002 at which time he had edema of the right knee that was treated with a knee immobilizer and crutches along with Indocin (indomethacin, a nonsteroidal anti-inflammatory drug (NSAID)), Tylenol (acetaminophen, a pain reliever), ice, and range of motion exercises.  The CI was seen in the Emergency Department on 10 August 2003 after jumping off a top bunk.  Examination revealed minimal edema, tenderness to palpation over the medial left knee and minimal increased pain with range of motion (ROM).  An MRI on 3 September 2003 revealed a residual abnormality of the PCL suggesting some fiber intactness with a substantial disruption suspected.  No meniscal tear was observed or any other ligamentous injury was detected.  Bone marrow edema was present in the area of the subchondral (below the cartilage) plateau both medially and laterally.  Orthopedic evaluation on 1 December 2003 for left knee pain and instability noted the CI reinjured his knee in August 2003 on uneven surfaces.  He felt weak and his knee gave out.  He also had locking of his knee in the mornings with associated swelling.    On examination he had a normal gait and had a ROM of the left knee of 0 to 130 degrees without any effusion.  There was positive patellar testing (apprehension, compression, and crepitus) with medial and lateral joint line tenderness and a negative McMurray test (to determine a meniscal tear).  A trace posterior drawer was present with negative posterior sag and negative quadriceps active tests (to determine rotary instability posteriorly and/or a torn PCL).  Quadriceps muscle atrophy was 1+.  There was no anterior laxity, but there was positive posterolateral laxity with external rotation and posterior drawer especially compared to the right.  The orthopedic assessment was minimal PCL laxity with MRI and physical examination findings consistent with no PCL deficiency and posterolateral corner laxity on physical examination, but poorly visualized on MRI.  Because of 18 months of nonoperative conservative treatment and persistent symptoms, diagnostic arthroscopy was recommended.  On 3 February 2004 the CI underwent arthroscopy because he had frequent complaints of knee pain and occasionally felt that his knee buckled while climbing stairs and gave way with forward translation of his femur on his tibia.  However, he denied any frank instability with activities such as racquetball or soccer.  He had no locking and no recurrent effusions.  Examination under anesthesia revealed the PCL was intact, and there was no evidence of degenerative changes, loose body, and chondromalacia or arthritic changes; and, the menisci were intact without a tear.  No reconstruction was carried out.  The postoperative diagnosis was left knee with grade 1 PCL laxity.  Postoperatively, physical therapy, rehabilitation and a PCL brace were instituted.  While the CI was offered a MMRB (MOS/Medical Retention Board) to reclassify to a non-combat specialty, he desired MEB instead.  

Despite arthroscopy and postoperative treatment, the chronic left knee pain 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 “Grade 2 PCL tear with no improvement status post left knee arthroscopy and rehab” for PEB adjudication.

During the 26 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported a left knee ligament tear and arthroscopy on the left knee and use of a “PCL brace for rest of life.”   The examiner annotated lower extremities (except feet) normal on the clinical evaluation section of DD Form 2808.  The 27 April 2004 NARSUM examination, 4 months prior to separation, noted complaints of continued knee pain and swelling when running, ruck marching or climbing stairs.  Physical examination showed the CI had a 1A Lachman (to determine anterior laxity) with a Grade 2 PCL posterior drawer.  The dial test (to determine posterolateral instability) was negative as was varus/valgus testing (to determine joint laxity) at 0 and 30 degrees.  Negative joint line tenderness was noted, but the CI did have some anterior pain.  The CI underwent physical therapy and took Motrin (ibuprofen, a NSAID) and used a PCL brace.  As a result he could not ruck march, carry weapons, or run for PT (physical training) and could only lift up to 60 pounds.  There was no VA examination proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left knee pain condition 0% rating, coded 5099-5003 (arthritis degenerative), citing no significant loss of joint motion.  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 demonstrate the presence of PCL ligamentous slight instability or laxity (5257), albeit it Grade 1 or 2 depending on the examiner, but sufficient enough to preclude ruck marching and running as well as lifting greater than 60 pounds, to support a 10% rating, but not sufficient to warrant a higher rating since the PCL was intact on arthroscopy and the CI was able to participate in soccer and racquetball.  However, there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating.  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 panel recommends a disability rating of 10% for the chronic knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic left knee pain condition, the panel unanimously recommends a disability rating of 10%, coded 5257 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Chronic Left Knee Pain	5257	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150610, w/atchs
Exhibit B.  Service Treatment Record

AR20170008500, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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