RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00322
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic left knee pain” with a disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20080728	VARD - 20090424	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Left Knee Patellofemoral Syndrome…	5260	10%	20080825	
Depression	Not Unfitting	Major Depressive Disorder	9435	10%	20090401	
Isolated elevated blood pressure	Not Unfitting	Hypertension	7101	NSC	20080825	
Hyperlipidemia	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee condition began in February 2007 after slipping on ice.  An MRI on 19 June 2007 noted mild meniscal degenerative changes in the posterior medial meniscus and was otherwise negative.  The CI was treated with medications and physical therapy without significant improvement.  In November 2008 the CI reported continued pain, crepitation, and instability of his knee.  The surgeon discussed options of diagnostic arthroscopy or P3 profile and the CI chose a permanent profile.  

The 9 January 2008 MEB NARSUM examination, 9 months prior to separation, noted complaints of constant pain in the left knee, with flare-ups at least once daily.  Physical examination showed no evidence of instability and patellar apprehension and grind test were negative.  The MEB examiner noted the CI used a cane and had a marked limp both with and without a cane.  Physical therapy measured range of motion (ROM) for the MEB on 31 January 2008, 8 months prior to separation, using a standard goniometer.  Left knee ROM following repetitive movement was flexion of 120 degrees (normal 140) and extension of 0 degrees (normal) with “ROM limitations secondary to pain.”  

A NARSUM addendum dated 24 March 2008, 6 months prior to separation, indicated there was no change from the previous knee ROM recorded and added that it could be speculated that the CI’s ROM would be reduced to flexion of 70 degrees and external rotation of 40 degrees during repeated movements or flare-ups.  A memorandum to the PEB dated 8 July 2008, 3 months prior to separation, reiterated the same information as the March NARSUM addendum.

At the 25 August 2008 VA Compensation and Pension (C&P) examination, one month before separation, the CI reported chronic left knee pain with decreased mobility, problems lifting, and lack of stamina.  Physical examination showed an antalgic gait and tenderness of the medial knee and patellar tendon.  There was no effusion, crepitus, locking, or patellar grind.  There was pain noted with testing for meniscal pathology.  Left knee ROM following repetitive movement was flexion of 120 degrees and extension was normal with painful motion.  There was no additional limitation of motion with repetitive testing.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing painful motion.  The VA also rated the left knee condition 10%, coded 5260 (leg, limitation of flexion), based on the C&P examination, citing painful motion of a major joint.  

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 painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45).  The panel considered other VASRD knee and analogous codes, but all were less applicable and not advantageous for rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.  

Contended PEB Conditions:  Depression, Isolated Elevated Blood Pressure, Hyperlipidemia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  

Depression.  The CI was referred by his case manager for psychological interview to determine the CI’s need for mental health services during the MEB process.  At the time of his first mental health examination with a psychologist on 6 December 2007, the CI reported difficulty sleeping, decreased energy, eating way too much, normal (euthymic) mood, and social withdrawal since return from deployment in Iraq.  He reported sensitivity to loud noises and waking up not well rested “fuming,” but not recalling any dreams.  He was on medication (Ambien) for sleep.  At a psychiatric examination on 28 January 2008, the CI reported increased irritability and social withdrawal since return from deployment.  He denied suicidal ideation.  He was on an antidepressant medication (Effexor) which he was tolerating well.  Mental status examination was normal with his stated mood being “pretty good.”  The diagnosis was depressive disorder, not otherwise specified (NOS) and was considered provisional, with post-traumatic stress disorder, major depressive disorder, dysthymic disorder, and/or a personality disorder still being considered.  His mental health condition was considered stable and met retention standards.  At a psychology follow-up visit in April 2004, the CI reported feeling down, but many psychosocial stressors were noted including marital separation, a speeding ticket, and recent administrative burdens.  A mental status examination was normal.  The CI stated his mood was “pretty good” and the examiner noted his affect was bright and pleasant.  The provisional diagnosis remained depressive disorder NOS, and it was “resolving.”  The MEB NARSUM addendum in March 2008 and the memorandum to the PEB in July 2008 both cited that the psychiatrist determined the CI’s MH condition met retention standards.  

The depression condition was not profiled or implicated in the commander’s statement and did not fail retention standards.  There was no performance-based evidence from the record that the depression 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 the depression condition, so no additional disability rating is recommended.  

Isolated Elevated Blood Pressure and Hyperlipidemia.  The isolated elevated blood pressure and hyperlipidemia conditions were not profiled or implicated in the commander’s statement and did not fail retention standards.  There was no performance-based evidence from the record that these 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 the blood pressure or hyperlipidemia conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended depression, isolated elevated blood pressure, and hyperlipidemia 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.  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 20170208, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180016324, 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.