RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00966
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “status post injury to right knee” with a disability rating of 0%.   

CI CONTENTION:  No specific contention made.  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 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 - 20031202	VARD - 20031107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Injury to Right Knee	5099-5003	0%	Status Post Debridement Tear of Lateral Meniscus  Right Knee	5262	10%	20050107	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Status Post Injury to Right Knee.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began on 19 June 2003 after she fell approximately 4-5 feet while navigating an obstacle course and landed on her right knee.  As a result she sustained a twisting mechanism injury and was evaluated in the emergency room where she was given a knee immobilizer, crutches, and Vicodin (hydrocodone, a narcotic, and acetaminophen, a pain reliever) for pain.  X-rays demonstrated a chip fracture of the center of the tibial plateau.  

At an orthopedic visit on 20 June 2003, the CI noted a history of arthroscopy 5-6 years earlier for repair of the right knee ligament (likely the anterior cruciate ligament (ACL)) and tendon injuries.  Physical examination revealed a moderate to large effusion with a decreased range of motion (ROM) of flexion and medial joint line tenderness with significant guarding during Lachman’s testing (to determine laxity).  X-rays demonstrated a chip fracture of the center of the tibial plateau which the orthopedic surgeon felt either represented an acute injury or possible some sequelae from previous surgery.  

Magnetic resonance imaging (MRI) on 11 July 2003 demonstrated a nondisplaced central tibial plateau fracture at the insertion site of the ACL. A partial tear was suspected.  An 8 mm bony fragment was in the femorotibial joint.  A traumatic vertical tear of the posterior horn of the lateral meniscus and an articular cartilage defect of the medial patellar facet were present.  At the time of an orthopedic appointment on 21 July 2003, the CI reported two episodes of giving-way and she continued to have popping without true locking.  Despite conservative treatment, her condition appeared to have deteriorated.  

On 30 July 2003, the CI underwent arthroscopic surgery of the right knee with debridement of an anterior horn lateral meniscal tear and a chondroplasty of the medial patellar facet; tricompartmental degenerative changes were noted. However, following the surgery, the CI underwent physical therapy and continued to report pain with activity including physical therapy.  By 6 October 2003 flexion improved to 120 degrees (normal 140) and on 20 October 2003, flexion improved to 136 degrees, with painful motion.  

The 7 November 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of pain and discomfort with kneeling, squatting, and prolonged sitting.  Pain was described as 3/10 and worsening with activity.  Popping was reported; however, no locking or giving way occurred, although there was some activity-related swelling in the right knee.  No medications for pain were taken.  Physical examination showed a normal reciprocal gait pattern without antalgia.  The arthroscopic wounds over the right knee were well healed and a trace effusion was noted.  ROM measurements showed a flexion of 135 degrees and a normal extension of 0 degrees.  No significant joint line tenderness was present, but she had patellofemoral crepitus (grinding) and a positive patellar grind test.  There was no laxity, instability (1A Lachman, negative pivot shift and intact to varus and valgus stress testing), or evidence of a meniscal tear (McMurray’s test negative).  

During the 10 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months before separation, the CI reported she was post-surgery for a meniscal tear, she still had a slight limp, her knee swelled with activity, and she used a knee brace.  The examiner checked normal for the lower extremities on the clinical evaluation, but noted the CI was unable to train secondary to pain in the right knee status post arthroscopy for a torn meniscus of the right knee.  
  
At the 7 January 2005 VA Compensation and Pension (C&P) evaluation, 12 months after separation, the CI reported tenderness over the medial and lateral aspect of the knee.  Besides surgery and postoperative physical therapy, she was treated with a knee brace. Physical examination showed her gait to be normal and she was in an advanced state of pregnancy.  There was tenderness over the medial and lateral aspects of the knee, but there was no swelling, deformity or instability demonstrated.  Active flexion was 120 degrees and extension -5 degrees.  No weakness, fatigability, decreased endurance, or incoordination was noted.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5099-5003 (arthritis, degenerative) citing the U.S. Army Physical Disability Agency pain policy.  The VA rated the right knee condition 10%, coded 5262 (tibia and fibula, impairment of), citing slight knee symptoms associated with complaints of pain and slight limitations on flexion and extension.  

There was no limitation of motion to support a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The 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) to support a rating under those respective codes.  There was no fracture, nonunion, 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, there was evidence of painful motion with functional loss at a physical therapy visit 3 months prior to separation along with crepitus and a positive patellar grind at the NARSUM examination to support a 10% rating (based on §4.59, §4.40 and §4.45) using code 5099-5003.  

The 5259 code (cartilage, semilunar, removal of, symptomatic) was also applicable in this case, and provided an alternate route to a 10% rating.  However, there was no VASRD §4.71a route to a rating higher than the 10% under any applicable 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 status post injury to right knee condition, coded 5259.  

BOARD FINDINGS:  In the matter of the right knee condition, the panel unanimously recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Status Post Injury to Right Knee	5259 	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160921, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018903, 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