RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02297
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Infantryman, medically separated for “chronic right anterior knee pain post anterior cruciate ligament reconstruction” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that his knee condition continues to worsen, and he contends for a condition not identified by either the MEB or PEB.  The 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 - 20030905	VARD - 20090901	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Anterior Knee Pain Post Anterior Cruciate Ligament Reconstruction…	5099-5003	0%	Right Knee Instability with Residual Scar	5257	10%	20090519	
			Osteoarthritis, Right Knee Status Post Anterior Cruciate Ligament Repair	5260	10%	20090519	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Right Anterior Knee Pain Post Anterior Cruciate Ligament (ACL) Reconstruction.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in November 2001 after he injured it playing football in unit physical training.  Initial radiographic studies showed a small subpatellar joint effusion.  After a year of physical therapy (PT) the CI underwent surgery to repair a torn right anterior cruciate ligament (ACL).  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic anterior knee pain” for PEB adjudication.  

At the orthopedics evaluation on 16 May 2003, 5 months before separation, the examiner noted the CI had chronic anterior right knee pain ranging from 3-4/10.  He complained of intermittent swelling and was wearing a brace.  Physical examination noted tenderness to palpation and positive patellar grind.  The range of motion (ROM) for his right knee was 0-130 degrees (normal 0-140).  The knee was stable to varus and valgus stress, with a negative Lachman's and negative anterior drawer (no laxity or instability).  The specialist indicated that there was no need for further surgical repairs.  

The MEB NARSUM, dated 4 August 2003, 3 months before separation, noted the CI continued to experience daily pain when attempting strenuous physical activity such as road marching or running.  It was noted that “His knee will sometimes give away and is unstable when he puts a lot of stress on it, and the pain can be severe at times.”  He was able to walk, however carrying any kind of weight in terms of a ruck sack gave him great difficulty.  He reported day-to-day walking was generally without pain, but stated he occasionally experienced flares, and he could not carry weight.  He was able to ambulate with a brace and was attempting to run a half mile per day.  An X-ray from May 2003 (14 months after surgery) showed a small joint effusion consistent with ACL repair.  The physical examination noted a retropatellar grind of the right knee with generalized tenderness above and around the patella.  There was minimal Lachman’s sign (ACL laxity) with good endpoints, no McMurray’s (meniscal testing) or varus/valgus laxity.  The ROM for his right knee was flexion of 140 degrees (normal) and extension of 0 degrees (normal), without specifying repetition or presence/absence of DeLuca criteria.  

At the 1 September 2009 VA Compensation and Pension (C&P) evaluation, performed 5 years and 7 months after separation, the CI reported constant pain in his right knee that traveled up and down the lateral right leg.  He reported the pain as aching and sharp and at worst at a 6/10 level.  He reported wearing a brace or an ace bandage for support once per month.  He also reported heat, stiffness, swelling and giving way/instability.  He reported that civilian diagnostic imaging indicated a re-tear of the ACL and a meniscus tear.  Physical examination showed edema, tenderness, heat and guarding of movement.  There was no weakness, redness, lack of endurance, locking, fatigability or dislocation.  Medial and lateral meniscus testing of the right knee was abnormal “with slight degree of severity.”  ROM was painful with flexion to 100 degrees (140 normal) and extension 0 degrees (normal).  X-rays showed retained fixation screw, small spurs and early osteoarthritis of the tibiofemoral joint.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded analogously as 5099-5003 (degenerative arthritis), referring to the condition being rated on “pain” as a reference to the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated the right knee condition 10%, coded 5257 (knee, other impairment of), citing “right knee instability and scar” and 10%, coded 5260 citing “osteoarthritis, right knee, status post ACL repair.”  

The Board adjudged that the Service examinations had the highest probative value for rating at the time of separation since the probative value of the VA examination was markedly decreased due to its remoteness from separation and indication of intervening re-injury to the right knee.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261), 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, examinations proximate to separation did demonstrate the presence of at least minimal ligamentous laxity (5257), symptoms of instability, use of a brace, and pain with movement of the patella; there was therefore evidence of pain and instability with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The Board adjudged that there was insufficient symptomatology for dual rating of the knee IAW VASRD §4.14 (avoidance of pyramiding).  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, 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic right anterior knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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 Anterior Knee Pain Status Post ACL Reconstruction	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004236, 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