RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01003
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040610

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, M1 Armor Crewman, medically separated for “chronic left knee pain” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  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 - 20040407	VARD - 20050418	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Symptomatic Removal of Semilunar Cartilage, Left Knee, Status-Post PCL Reconstruction, with Degenerative Joint Disease, Pain, and Limitation of Motion	5258	20%	20040723	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgery in August 2001 for torn posterior cruciate ligament and lateral collateral ligament.  His rehabilitation was successful, but while deployed in September 2003 his knee became very painful and started locking.  Radiographic studies in December 2003 showed findings consistent with his prior surgery with no acute injuries, but there was chondromalacia involving the dorsal surface of the knee cap.  At the 19 December 2003 physical therapy examination, 6 months prior to separation, the CI reported that he had to stop his lower extremity exercises because they caused too much pain.  He also complained of pain with extension.  On examination his range of motion (ROM) was 0 degrees extension (normal 0) and 130 degrees of flexion (normal 140) with slight (4-/5) muscle weakness in the quad due to pain.  There was minimal effusion.  There was positive varus stress gapping at 30 degrees.  

At the 30 December 2003 orthopedic examination, 5 months prior to separation, the CI complained of left knee pain and instability with frequent buckling.  He also reported peroneal nerve weakness with decreased sensation over the foot.  On examination he had 5 degrees of extension and 115 degrees of flexion.  There was no effusion.  Although he was stable to valgus and varus stress at 0 degrees, there was 1+ laxity to varus stress at 30 degrees.  There was also muscle weakness in the left lower extremity with decreased sensation, but his reflexes were normal.  During the 26 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported continuous left knee pain.  Physical examination showed decreased flexion, but the examiner did not provide the actual measurement.  At the 6 February 2004 MEB ROM study, 4 months prior to separation, after repetitive motion, the CI had 0 degrees of extension and 130 degrees of flexion.  There was no report of painful motion.  The 5 March 2004 MEB NARSUM examination, 3 months prior to separation, showed no effusion and provocative maneuvers to detect knee instability or meniscal pathology were negative, but the examiner did note the CI guarded against the pivot-shift test.  Muscle strength was normal.  

At the 23 July 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported daily left knee pain that increased with standing more than 10 minutes, sitting more than 15-30 minutes or with prolonged walking.  He also reported swelling with prolonged standing, but denied any weakness, instability or locking.  Physical examination showed a normal gait with no left knee swelling, deformity or tenderness.  There was slight discomfort without motion on stressing the posterior cruciate ligament, but all other left knee ligaments were intact.  The examiner noted that there was no instability or joint laxity.  Provocative maneuvers to detect meniscal pathology were negative.  ROM testing showed extension of 0 degrees and flexion of 125 degrees.  Lower extremity muscle strength was normal.  Radiographic studies showed minimal degenerative changes in the left knee.  The examiner opined that there was “the presence of painful motion in the left knee, without weakness, fatigability, incoordination or instability. This [was] supported by objective evidence and [was] consistent with the history and pathology of the disability.”  The examiner estimated that the “pain, weakness, incoordination, etc. could not significantly limit functional ability when the joint [was] used repeatedly over a period of time.”  He estimated that there was “no additional degrees of ROM lost with excessive use.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded analogous as 5003 (degenerative arthritis), citing no significant loss of motion.  The VA originally rated the left knee condition at 10% under code 5259 (cartilage, semilunar, removal of, symptomatic) and 10% under code 5010-5260 (traumatic arthritis causing limitation of flexion) for a combined rating of 20%, based on the C&P examination dated 23 July 2004.  However, the VA later changed the rating to 20% under code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint), based on the same C&P examination after a special internal review of the CI’s file, citing that the C&P examination “showed that [the CI] had left knee pain, pain with repetitive motion, additional loss of range of motion with repetitive motion, degenerative joint disease, and a history of surgical PCL reconstruction.”  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 or evidence 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 those code(s).  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, based on the C&P examination proximate to separation, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 left knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the left knee condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 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	
Chronic Left Knee Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160927, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018564, 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