RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00389
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050921

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E1, Basic Training Trainee, medically separated for “right knee pain” with a disability rating of 0%.  

CI CONTENTION:  The CI did not submit a specific contention within the application.  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20050901	VARD - 20060202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee	5099-5003	0%	Subluxation and Dislocation of the Right Patella	5257	0%	STR	
			Arthritis of the Right Knee	5010-5260	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Knee Pain. According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in May 2005 during Basic Training when the right patella dislocated associated with throwing a grenade during training.  At an 11 June 2005 acute care visit the CI reported repeated knee “buckling” and swelling.  Physical examination noted effusion and limited range of motion and patellar subluxation was diagnosed.  The CI was given crutches and a knee immobilizer.  At a 14 June 2005 physical therapy visit the CI reported she fell the night before.  She reported patellar pain and felt her knee was unstable and weak and it felt like “kneecap shifting a lot.”  Magnetic resonance imaging (MRI) performed on 28 June 2005 showed a moderate joint effusion and possible medial retinacular tear (MRT-soft tissue on the medial patella).  

At the 25 July 2005 physical therapy clinic appointment, 2 months before separation, the CI reported continued pain of the right knee aggravated by activity.  The therapist noted that the CI had been diagnosed with a MRT consistent with an initial injury of patellar dislocation as opposed to subluxation.  Physical examination showed full knee range of motion with pain with flexion.  There was pain with patellar compression and pain with single leg stand and squats.  There was no evidence of knee joint instability or meniscal pathology.  The CI declined surgical intervention and was referred to orthopedics for MEB determination  

At the 4 August 2005 orthopedic clinic visit, 2 months prior to separation, physical examination showed a normal gait.  It was also noted that the CI had five signs of general ligamentous laxity.  Both lower extremities were neurovascularly intact.  Knee range of motion (ROM) was “full.”  Ligaments were stable bilaterally.  There was tenderness to palpation over the medial aspect of the right knee and patella.  There was no effusion or joint line tenderness.  There was a mild J-sign (lateral patellar deviation) on tracking and a positive apprehension test of both patellae.  The CI again declined surgical intervention and MEB was initiated.

The 17 August 2005 MEB NARSUM, 1 month prior to separation, noted the CI had significant dysfunction “due to the pain in her knees.”  She was not able to run, jump or perform most of the activities of military life.  The MEB physical examination noted the CI had a normal gait, and lateral patellar deviation bilaterally, left worse than right.  There was tenderness over the medial aspect of the knees and patellae bilaterally.  The examiner noted the CI “had a fairly loose kneecap” but did not differentiate whether it was the right or left.  There was no joint line tenderness medially or laterally.  There was no evidence of knee joint instability (cruciate and collateral ligaments) were intact.  Knees had “full range of motion from 5 degrees of hyperextension to approximately 125 to 130 degrees of flexion.”  Bilateral knee radiographic (X-ray) studies showed no evidence of arthritis.  There was no VA Compensation and Pension (C&P) evaluation proximate to separation in evidence.  

The panel 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), citing slight and occasional pain IAW the US Army Physical Disability Agency pain policy/AR 635-40.  The VA rated the right knee condition 0%, coded 5257 (knee, other impairment of; recurrent subluxation or lateral instability), based on the STR and citing failure to report for a scheduled VA examination.  The VA did not service connect an arthritis condition of the right knee, coded 5010-5260.  
 
There was evidence to support a 10% rating for other knee impairment (5257) for “slight” recurrent subluxation or lateral instability.  The panel judged that the evidence at the orthopedic evaluation 2 months before separation and the MEB NARSUM examination of normal gait, tenderness, with full ROM and without effusion or documentation of painful motion did not provide sufficient support for the next higher rating for “moderate” recurrent subluxation or lateral instability.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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).  There was therefore no higher rating than 10% available with any applicable VASRD code.  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 right knee condition, 5257.  

BOARD FINDINGS:  In the matter of the right knee 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	
Right Knee	5257	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160610, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Rating Decision

AR20170015457, 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