RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pd-2016-00138
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20061015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Patriot Missile Operator/Maintainer, medically separated for “left knee pain” with a disability rating of 0%.   

CI CONTENTION:  The CI contended for his left wrist and several other conditions in addition to his unfitting left knee.  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 - 20060815	VARD - 20070606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	0%	Osteoarthritis, Left Knee	5003	0%	20061012	
			Residual Scar, Left Knee	7805	0%	20061012	
Left Wrist Arthritis	Not Unfitting	Osteoarthritis, Left Wrist	5003	0%	20061012	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an injury to his left knee in 2003 and underwent a surgical repair of a torn ligament (medial collateral).  Pain persisted, and although there was no clear documentation of subsequent injury, imaging (MRI) in June 2005 demonstrated a lateral meniscal tear with “mild” osteoarthritis (all ligaments intact); and, in November 2005 (11 months before separation) he underwent an arthroscopic meniscectomy.  

Several post-operative orthopedic entries documented persistent pain with increasing activity; but, noted that there were no complaints of subjective instability or locking, and that there was no effusion or instability by examination.  The orthopedic entries also provided serial range of motion (ROM) measurements, with flexion in the range of 105-115 degrees (normal 140, 45 for minimum 10%) and 0 degrees extension (normal), specifying no painful motion.  There were no STR entries contrary to this ratable evidence.  
  
The 15 May 2006 NARSUM examination was supplemented by an addendum dated 5 July 2006 (3 months before separation).  The examiner documented that the CI “continues to have mild to moderate pain ... [that] ... does not permit him to climb ladders or run in gear.”  The physical examination recorded tenderness, the absence of effusion, and stability to stress testing.  Measured ROM was flexion to 105 degrees with 0 degrees extension, specifying “moderate” painful motion.  

The 12 October 2006 VA Compensation and Pension (C&P) evaluation, 3 days prior to separation, documented “stiffness and discomfort” that prohibited running and that was aggravated by walking, prolonged sitting or standing, and stairs.  The physical examination recorded a normal gait, tenderness, no effusion, stability to stress testing, negative signs of impingement (locking), and “normal ROM” without pain or degradation on repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5099-5003 (analogous to degenerative arthritis) stated only “rated for arthritis” and did not address painful motion.  The VA‘s 0% rating under code 5003 cited the C&P evidence for normal ROM without painful motion.

There was conflicting evidence with regard to painful motion, including specific documentation of the absence of painful motion at the time of separation by the C&P examiner.  The directed evidence for painful motion by the NARSUM examiner, nevertheless, was a reasonable doubt argument for conceding painful motion in support of a minimum 10% rating IAW VASRD §4.59.  Furthermore, IAW VASRD §4.7 (higher of two evaluations), the application of code 5259 (cartilage, semilunar, removal of, symptomatic) was easily justified in this case and provides for a 10% rating independently of any other criterion.  There was no evidence for ROM limitation, persistent effusion and locking, instability, or fracture with nonunion or malunion to support a rating higher than 10% under any applicable code.  

After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the left knee condition under code 5259.

Contended PEB Condition:  Left Wrist Pain.  The CI suffered a fracture of his dominant left wrist in 2003 that required surgical correction (successful ORIF for ulnar nonunion).  The pain persisted and he was subsequently diagnosed with ligamental tears (scapholunate and lunotriquetral by arthrogram).  He underwent an arthroscopic repair in September 2004 (2 years before separation).  An orthopedic entry of 7 June 2004 (4 months before separation) documented normal measured ROM and grip strength.

The NARSUM documented nonspecific pain without elaborating functional limitations or providing physical findings, although the examiner stated that the “wrist pain is not additionally limiting compared with his knee pain.”  That notwithstanding, the wrist condition was forwarded to the PEB as failing retention standards.  

The condition was profiled permanent U2 (a level 2 profile does not mandate MEB referral and does not typically impose unfitting limitations).  Specifically the profile permitted carrying and firing of a weapon.  The commander’s performance statement referenced wrist problems, but elaborated mostly lower extremity limitations (jumping, lifting, “laying out cables,” and running). 

The VA C&P examination on the eve of separation documented “mild” tenderness, normal ROM, and no pain with repetition.  The examiner cited interference with extended writing or keyboard activity, but also mentioned “difficulty firing his weapon.”

The panel directed attention to its recommendation based on the above evidence, and its main charge was an assessment of the fairness of the PEB’s determination that the left wrist condition was not unfitting.  Although judged to fail retention standards, the NARSUM language seemed ambivalent in that regard.  The commander did not clearly implicate the wrist.  The C&P comment about difficulty firing a weapon was considered, but was in opposition to the profile specification.  Members ultimately agreed that there was insufficient performance-based evidence that indicated the condition interfered with duty requirements to an extent that would have prohibited further military service.  

After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left wrist condition, thus it was not eligible for service rating.  

BOARD FINDINGS:  In the matter of the left knee condition, the panel unanimously recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  In the matter of the contended left wrist condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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 his prior medical separation:    

CONDITION	VASRD CODE	PERMANENT RATING	
Arthritis with Surgical Residuals of Meniscectomy, Left Knee	5259	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160309, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170014070, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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