RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01539
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Heavy Construction Equipment Operator, medically separated for “chronic left knee pain” with a disability rating of 10%.  

CI CONTENTION:  Requested review of left ear hearing loss, left knee, nerve damage in the left leg, shoulder pain and depression as well as additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation. 

RATING COMPARISON:  

SERVICE PEB - 20041129	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5299-5257	10%	No VA Examination Proximate to Separation in Evidence	
Hearing Loss	EPTS		
Right Shoulder Pain	EPTS		
Dysthymic Disorder	EPTS		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY

Chronic Left Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee condition began while at her civilian job in 1992.  She underwent three surgeries, with the last (January 2000) a revision of the left knee anterior cruciate ligament (ACL) repair with an allograft.  Left knee X-rays in May 2000 demonstrated “apparent satisfactory appearance of the left knee” with no acute abnormality detected.  Despite surgery and postoperative physical therapy, the CI continued to have persistent knee pain and weakness.  Because she had reached maximal medical benefit, no further treatment was recommended and she was not a candidate for repeat reconstruction.    During the 4 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported left knee pain and occasional edema, and sometimes wore a knee brace.  Physical examination showed tenderness and decreased range of motion (ROM).  

The MEB NARSUM examination, on the same day, noted complaints of left knee pain every other day that lasted for about a quarter of the day.  Her average pain level was 5-6/10 and reached 8-9/10 twice a week, and was exacerbated by walking greater than a half mile, lifting over 20-25 pounds, climbing stairs, running, or playing sports.  The CI stated that she occasionally tripped because she could not bend her knee far enough.  Additionally, her knee would “lock up” about 3-4 times a year and “partially” give out and feel “very weak” on rare occasions.  She reported left leg numbness, particularly on the lateral side, from the distal third of the thigh down to the proximal lower leg.  Physical examination showed: tenderness along the left lateral knee without joint tenderness or effusion; 5 mm varus and valgus stress and 3+ anterior drawer and Lachman tests with firm endpoint on the left; negative McMurray sign (to determine a meniscal tear); positive joint crepitus bilaterally; and no atrophy.  The CI’s gait was not antalgic when she was distracted.  The examiner noted that she had been unable to drill with her unit since September 1999 and she was terminated from her civilian job due to physical disability.  Physical therapy ROM measurements for the MEB on 4 October 2004 recorded left knee flexion to 50 degrees (normal 140) and extension to 2 degrees (normal 0). Right knee ROM was flexion to 90 degrees and extension to 4 degrees.  There was no VA examination proximate to separation in evidence.
  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5299-5257 (knee, other impairment of: recurrent subluxation or lateral instability), citing a 3+ Lachman’s sign.  Members agreed that the NARSUM examination findings demonstrated the presence of ligamentous instability or laxity and deliberated over whether the disability was “moderate” or “severe.”  While the CI did not have an antalgic gait, she occasionally tripped and her knee locked up a few times a year due to instability.  However, based on her history of three surgical procedures related to the ACL (the most recent was almost 5 years prior to separation) and her limited interaction with either orthopedic surgeons or rehabilitation specialists, members agreed her left knee condition was best described as moderate and did not rise to a severe level warranting a 30%.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating.  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).  While a 10% rating was warranted for NARSUM ROM measurements showing flexion of 50 degrees, to rate both the instability and limitation of motion would invoke VASRD §4.14 (avoidance of pyramiding) in the absence of painful motion.  There was therefore no VASRD grounds for additional rating based on the presence of instability.  The 5259 code (cartilage, semilunar, removal of, symptomatic) was also applicable in this case, but the maximum 10% rating provided no benefit to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left knee pain condition, coded 5257.  

Contended PEB Conditions:  Hearing Loss, Dysthymic Disorder (Late Onset), Right Shoulder Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  
BOARD FINDINGS:  In the matter of the chronic left knee pain condition, the panel recommends a disability rating of 20%, coded 5257 IAW VASRD §4.71a.  In the matter of the contended hearing loss, dysthymic disorder and right shoulder conditions, the panel recommends no change from the PEB determinations as not unfitting.  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	
Chronic Left Knee Pain	5257	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161017, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180004647, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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