RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01939
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Military Police, medically separated for “chronic  knee pain,” with a  disability rating of 0%.  

CI CONTENTION:  The CI contends that several treated conditions were not considered at time of discharge.  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 - 20070410	VARD - 20080416	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5003	0%	Right Knee Chondromalacia…	5099-5014	10%	20070827	
Sleep Apnea	Not Unfitting	Sleep Apnea	6847	50%	20070827	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Knee Diagnosis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began while running in 2002 when her knee “popped out.”  Radiographic studies demonstrated narrowing of the patellofemoral space with degenerative changes and suspicion of meniscal tear.  The CI underwent surgical arthroscopy December 2003 with findings of chondromalacia, Grade II, and no meniscal tear.  A second arthroscopy was performed in June 2006 due to worsening of the CI’s symptoms.  

Despite treatment, the knee 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 “right knee pain” and “sleep apnea” for PEB adjudication.  

At the November 2006 MEB examination (recorded on DD Forms 2807 and 2808), 7 months prior to separation, the CI reported the right knee swelling all the time resulting in the right foot becoming numb with a sense of the right knee “locking-up” and having difficulty bending.  

The MEB orthopedic NARSUM examination on 9 November 2006, 7 months prior to separation, noted complaints of not being able to run, carry gear, or perform military duties.  The CI reported occasionally taking Tylenol for the pain.  Physical examination showed “full range of motion” with no effusion or instability.  There was tenderness to palpation over the patellofemoral area as well as along the lateral joint line.  The McMurray's test (for meniscal pathology) was negative.  

At the 27 August 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported right knee pain especially when walking; swelling resulting in the right foot becoming numb; locking at times with prolonged standing; instability and weakness.  The CI reported wearing a brace for prolonged activities with limitations of walking 1 mile and standing 20 minutes.  Physical examination showed a mildly antalgic gait.  The right knee demonstrated sub-patellar tenderness, with popping and grinding with range of motion (ROM).  ROM was flexion with pain to 120 degrees (normal 140) and extension to 0 degrees (normal), with flexion decreased to 115 degrees on repetition due to pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 0%, coded 5003 (arthritis, degenerative), citing major joint with radiographic evidence of degenerative joint disease and no loss of motion.  The VA rated the knee condition 10%, coded 5099-5014 (analogous to osteomalacia), based on the VA C&P examination 2 months after separation, citing ROM decreased with sub-patellar popping and grinding.  

The Board noted the disparity between the NARSUM and VA examinations and carefully reviewed the evidence proximate to separation to determine the probative value of each. The NARSUM examination was more remote from separation, did not address gait, goniometric measurement, note the absence or presence of painful motion, or address repetitive motion.  The VA examination was closer to separation, was more detailed, addressed gait, used a goniometer (IAW VASRD §4.46 - Accurate Measurement), and addressed repetitive motion.  The Board adjudged that the VA examination had the highest probative value for rating at separation.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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.  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).  However, the VA examination documented painful motion and 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 right knee condition, coded 5003.  

Contended Condition:  Sleep Apnea.  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 profiled and judged to fail retention standards, but was not implicated in the commander’s statement.  The MEB NARSUM examination on 4 March 2007, 3 months prior to separation, detailed that the CI was compliant and stable with prescribed setting of the CPAP machine (continuous 	positive airway pressure, a breathing assistance device) with no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  Routinely sleep apnea is not considered unfitting solely on the basis of field and operational impediments to the use of CPAP.  There is no evidence in this case that sleep apnea was associated with any functional impairments that were not corrected by CPAP.  Accordingly, members concurred that the PEB’s fitness determination was reasonable; and, after due deliberation, the Board finds insufficient cause to recommend a change in the PEB adjudication of the sleep apnea condition.  

BOARD FINDINGS:  In the matter of the knee condition, the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the contended sleep apnea condition, the Board unanimously recommends no change from the PEB determination 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	
Chronic Right Knee Pain	5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150713, with 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018772 (PD201501939)

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 10% 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