RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE: PD-2016-00265
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040713

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E4, Cannon Crewman, medically separated for “chronic right anterior knee pain…,” with a disability rating of 10%.  

CI CONTENTION:  He was found unfit and made to separate without a medical profile so he could have retired.  The Army only gave him a one part rating for his right knee when it was a two part rating.  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 - 20040203	VARD - 20050324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Anterior Knee Pain	5099-5003	10%	Chronic Right Knee Sprain, Status Post Injury and Several Procedures 	5260	10%	20050208	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Knee pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first developed right knee pain in 2001.  This was attributed to both a fall after stepping into a hole while carrying a 98 pound box of ammunition and to a motor vehicle accident.  The variance in history had no impact on the adjudication recommendation.  Regardless, the CI underwent surgery for the right knee in January 2002 and again on 20 March 2003.  At the second surgery, repair of a lateral meniscus tear (LMT) was accomplished.  Degeneration of the cartilage lining of the joint and kneecap (patella) was noted as well.  The knee was stable without ligamentous laxity.  Following surgery, the CI underwent rehabilitation in physical therapy, but was not able to return to full duty.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 24 October 2003, 9 months prior to separation, the CI reported daily swelling in his right knee and a requirement to wear a knee brace.  Decreased range of motion (ROM) was observed, but not quantified.  The MEB NARSUM physical examination was performed by an orthopedic surgeon on 18 December 2003, 7 months prior to separation, and showed a well healed incision.  A patellar grind (pushing the patella against the knee) reproduced his symptoms.  The knee was stable on examination.  X-rays showed preserved joint space without degenerative changes.  Flexion was reduced to 120 degrees with normal (0 degrees) extension.  

On 9 February 2004, 5 months prior to separation, the CI was evaluated by a neurologist for an occupational assessment.  He used a cane, but the gait and posture were noted to be unremarkable (normal).  Flexion was limited to 110 degrees (140 is normal) and painful.  Motor function was normal and atrophy was not recorded.  The CI was seen in primary care for disability paperwork completion on 14 July 2004, the day after separation.  Flexion was limited to 90 degrees and the lateral collateral ligament was “loose” compared to the non-injured left side.  

At the VA Compensation and Pension (C&P) evaluation on 8 February 2005, 7 months after separation, the CI reported that his knee gave way if he did not wear his knee brace.  He reported constant pain.  The physical examination showed mild swelling and a limping gait with extreme guarding of his right knee.  The ROM was noted to have flexion from 0-95 degrees (normal extension, but reduced flexion).  It also noted a 10 degree lag in extension, but did not record if this was a limit before pain and if the CI could extend past it.  However, flexion from 0 to 95 degrees implies full extension.  The panel could not reconcile these two statements.  Pain with motion was noted.  The examiner also stated he had medial (col)lateral instability of the right knee.  Right knee X-rays were normal with no signs of fracture or dislocation.  

At the time of the Physical Medicine and Rehabilitation appointment on 23 June 2005, the examiner noted no effusion, no medial or lateral instability, and minimal crepitus (an abnormal grinding sound or sensation with movement).  A decrease in quadriceps muscle mass was present compared to the left side.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee pain condition 10%, analogously coded as 5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated the right knee pain condition 10%, coded 5260 (limitation of extension of leg), based on the C&P examination 7 months after separation, citing painful motion.  The VA also provided an additional 10% rating, coded 5257 (other impairment of the knee) for right knee instability based on the same VA C&P examination.  Painful and limited flexion supported a 10% rating under the codes 5260 and 5003 based on §4.59, §4.40 and §4.45 as adjudicated by the PEB.  Extension was typically normal other than the VA examination which was internally inconsistent.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  Instability was noted on the VA C&P examination and a primary care evaluation.  However, it was not present when the CI was examined at surgery, on the NARSUM examination by an orthopedic surgeon, or an examination by a physiatrist which was after the two examinations that recorded instability.  The panel also observed that one examiner recorded laxity of the medial collateral ligament and the other laxity of the lateral collateral ligament; these are on opposite sides of the knee.  The preponderance of evidence and the level of expertise of the examiners both support a finding that the right knee was stable at separation.  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.  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’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 20160913 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
AR20170015236, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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