RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01739
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20041029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Trainee, medically separated for “right knee injury during basic” with a disability rating of 0%.  

CI CONTENTION:  “Torn right ACL ligament, chronic lumbosacral strain (claimed as back condition).”  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 - 20040914	VARD - 20081219	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Injury During Basic	5257	0%	Status Post Anterior Cruciate Ligament Tear and Arthroscopic Repair, Right Knee	5299-5260	0%*	20081030*	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	
*Remote exam/rating after corrective surgery.  

ANALYSIS SUMMARY:  

Right Knee Injury During Basic.  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 2004 after falling during an obstacle course exercise at basic training.  X-rays of the knee revealed no gross anomaly, but magnetic resonance imaging (MRI) was reported as showing a tear of the anterior cruciate ligament (ACL) with bruising of the medial femoral condyle, with meniscus injury noted by orthopedic review (but note as no meniscal injury noted in the NARSUM).  Surgery was recommended, but the CI declined and elected to postpone surgery until after she left active duty.  
The 16 August 2004 MEB NARSUM examination, 2 months prior to separation, showed right knee range of motion (ROM) following repetitive movement was flexion 130 degrees (normal 140) and extension 0 degrees (normal 0) with pain occurring at extreme ranges of motion.  There was positive testing for ACL laxity including a 2+ Lachman’s with a soft endpoint, a positive anterior drawer test, and a 1+ pivot shift test.  There was no laxity with varus/valgus stress.  The physician recommended forwarding to the PEB IAW “AR40-501, Chapter 3, paragraph 13c, internal derangement of the knee, and sub-paragraph 1- residual instability following remedial measures if more than moderate in degree.”  

A follow-up MRI conducted on 7 December 2004, 1 month after separation, reported findings consistent with subacute to chronic ACL tear with associated meniscal tears involving both posterior horns of the medial and lateral menisci.  At the time of her 2 May 2005 orthopedic clinic visit, 6 months after separation, the CI reported she had been having difficulty with her knee hurting and “trying to give out.”  The examiner reported a normal gait, with “reasonably good” position and alignment of the right knee.  The drawer sign was still positive but he reported gross stability was otherwise reasonably good and the patella tracked well within the intercondylar groove of the femur.  

According to notes in the VA Compensation and Pension (C&P) examination conducted on 30 October 2008, 4 years after separation, the history indicated that the CI underwent arthroscopic surgery for her right knee ACL and meniscus tear on 5 May 2005.  There was scant evidence of treatment for her right knee in the record for the period between that surgery and the October 2008 C&P examination, which showed a normal gait, full ROM without painful motion, crepitus, or tenderness; and without instability or meniscal signs.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rating included the two MEB diagnoses of “right knee pain” and instability secondary to ACL disruption and bone bruise….”  The PEB rated the right knee condition 0%, coded 5257 (knee, other impairment of, recurrent subluxation or lateral instability), citing the CI’s decision to postpone surgery until after separation and stating that the physical examination was non-contributory to the rating.  Although not specifically stated in the findings, the PEB is believed to have applied DoDI 1332.39 para 6.1.3 (rescinded in 2008), which allowed for reduction of disability rating when a service member fails to comply with prescribed treatment, thereby aggravating or increasing the degree of disability.  The VA rated the right knee condition 0%, coded 5299-5260 (analogous to limitation of flexion of the leg), based on the C&P examination 4 years after separation (and after corrective surgery), citing noncompensable symptoms of limitation of motion, instability, or painful motion.  

In deliberating a VASRD-compliant rating under the 5257 code (knee, other impairment of; recurrent subluxation or lateral instability), the panel considered that the NARSUM findings of a 2+ Lachman with soft endpoint with a 1+ pivot shift test finding, and positive anterior drawer test, represented moderate to severe laxity.  However, since there were not severe symptoms of instability, the panel adjudged that the knee instability was closest to the moderate (20%) rating disability picture.  Given the two PEB diagnoses and the knee pain, the panel deliberated if dual rating of the knee was warranted for painful motion or meniscal symptoms.  

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  Although there was MRI evidence of some meniscal injury, there was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery (prior to separation) to remove a meniscus (5259) to support a rating under those 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).  There was therefore no additional functional limitation evidenced by the examinations to warrant dual coding of the knee.  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 right knee condition, coded 5257.  

BOARD FINDINGS:  In the matter of the right knee condition, the panel unanimously recommends a disability rating of 20%, 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 Instability	5257	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161112, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170019809, 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