RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01557
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20041127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O3, Chaplain, medically separated for “left knee pain” with a disability rating of 10%.  

CI CONTENTION:  The Army did not rate his right knee and he received a higher rating from the VA.  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 Medical Evaluation Board (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 - 20040827	VARD - 20050314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5259	10%	Left Knee LCL and MCL Instability	5257	20%	20041008	
			Degenerative Joint Disease, Posttraumatic Left Knee	5259	10%		
Right Knee Pain	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgery in 1987 for anterior cruciate ligament (ACL) reconstruction.  He was cleared for accession, but re-injured his left knee in November 2000 playing football.  Despite treatment, his pain persisted and on 22 March 2002 he underwent a diagnostic left knee arthroscopy which revealed an osteochondral defect and ACL insufficiency.  The examination was otherwise unremarkable including the medial and lateral collateral ligaments (MCL and LCL) and both menisci.  An orthopedic examination in February 2003 showed full bilateral knee range of motion (ROM), negative valgus (toward midline), negative varus (away from midline) and negative anterior posterior laxity.  The record was silent until an orthopedic appointment on 29 January 2004, 10 months prior to separation, where the CI complained of left knee instability for the previous 5 months.  The physical examination showed tenderness, a positive 2A Lachman and positive pivot shift (both consistent with an ACL repair/deficiency), but there was a negative post drawer test and negative varus/valgus stress test.  Findings suggestive of a meniscal tear were also present.  At a follow up orthopedic appointment on 8 April 2004, 8 months prior to separation, a different examiner noted that there was tenderness, but full ROM with no effusion,  no pain with patellar grind, intact ligaments, and stability to varus/valgus stress testing.  The examiner noted that an MRI showed intact ACL graft and medial meniscus.  Lateral compartment changes were seen on X-ray consistent with a prior lateral meniscal repair.  

The 9 June 2004 MEB NARSUM, 6 months prior to separation, noted complaints of progressive left knee pain.  The CI reported infrequent locking (about once a month).  He denied effusions, instability, or buckling.  The physical examination showed no effusion and full active ROM of the left knee.  There was moderate medial and pronounced lateral joint laxity, but the knee was also noted to be stable to varus and valgus stress.  There was tenderness to palpation.  Patellar grind produced no pain and the ligaments (anterior and posterior cruciate) were intact.  Painful motion was not documented.  

At the 8 October 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI stated that “the knee occasionally will lock if he tries to carry too much or if he walks on uneven ground, but it does not give way or collapse.”  On physical examination, the CI was noted to have a normal gait.  ROM testing showed extension of 0 degrees (normal) and flexion of 135 degrees (normal 140), without pain.  The ROM of the right knee was not recorded. There was moderate lateral and medial collateral ligament instability.  There was mild anterior and posterior cruciate instability.  There was patellar crepitus and patellar pain with patellar motion and a mild amount of sub patellar fluid.  McMurray’s signs were positive.  

Six months after separation, the CI was seen by a family nurse practitioner on 13 May 2005.  The CI reported ongoing pain and requested a referral to orthopedics.  On examination, the ROM was full, but painful.  Medial and lateral instability was present, but there was no anterior or posterior instability.  One week later in physical therapy, no signs of instability were present, but flexion was reduced to 115 degrees (vice 135 on the right).  Strength was intact and atrophy absent.  Two days later in orthopedics, the knee was stable in all planes and without an effusion.  Tenderness to patellar compression was present.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5259 (cartilage, semilunar, removal of, symptomatic), citing full active ROM and stability.  The VA rated the left knee condition 20%, coded 5257 (knee, other impairment of: recurrent subluxation or lateral instability: moderate), citing objective findings of moderate LCL and MCL collateral ligament instability.  The VA also rated the left knee condition 10%, coded 5259, citing symptomatic removal of the semilunar cartilage.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However there was evidence of pain with motion and a history of lateral meniscal repair, which warranted a 10% rating under the 5259 code (cartilage, semilunar, removal of symptomatic).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under that code.  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).  

The CI contended for the instability rated by the VA and the PEB noted that the left knee was stable.  Although some examinations recorded that instability was present, these were not completely consistent with each other and were performed by primary care clinicians.  The orthopedic evaluations most proximate to separation, both before and after separation, and a physical therapy evaluation after separation all noted a stable left knee.  The evidence does not support the presence of an unfitting (or ratable) instability at separation.  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 left knee pain condition.  

Contended PEB Condition:  Right Knee Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or judged to fail retention standards.  However, it was implicated in the commander’s statement, but there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20161015, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004013, 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