RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00501
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20080602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Trainee, medically separated for “chronic left knee pain status post arthroscopic surgery for cartilage debridement” with a disability rating of 10%.  

CI CONTENTION: Household chores, getting out of bed, and spending time with his daughter are all difficult and painful. He has to stop at work to rest and his pain medication isn’t helping.  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 - 20080306	VARD - 20081217	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Chondromalacia Patella, Left Knee, S/P Arthroscopy X 2	5260	10%	20081124	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI underwent an arthroscopic intervention for his left knee in March 2007 (3 months prior to service entry, but 3 months after entry physical).  He completed basic training, but re-injured the knee prior to commencing advanced individual training, and presented several weeks later with persistent pain.  Imaging (MRI) at that time demonstrated findings consistent with chondromalacia (damaged joint cartilage) and an osteochondral defect (small area of destroyed cartilage).  The menisci and all ligaments were intact.  There were no STR entries that suggested any more significant range of motion (ROM) limitation or more functional impairment than that presented below; and, none that indicated the presence of a persistent effusion and locking or any other VASRD-ratable findings.

The 4 January 2008 MEB NARSUM examination, 5 months prior to separation, documented knee pain “80-50% of the time” that prohibited running, lifting greater than 20 pounds, prolonged standing and walking without rest breaks, and multiple general soldiering requirements.  The physical examination recorded “a moderately severe antalgic gait,” tenderness, crepitus, no effusion or instability, and no indication of impingement.  The NARSUM cited goniometric ROM measurements by physical therapy performed on the same day.  These were flexion to 130 degrees (normal 140) and hyperextension of 8 degrees (normal 0, hyperextension not ratable), specifying painful motion.  Of note, the unaffected right knee also demonstrated hyperextension to 20 degrees, and there was confirmation in the VA history that this was a baseline for the CI. 

During an orthopedic consultation one week after the NARSUM examination, the examiner documented “pain with activities,” occasional subjective locking, and “problems negotiating stairs or sitting for long periods of time.”  The physical examination recorded tenderness, no effusion, patellar apprehension without joint instability, no indication of impingement, and “painful” flexion to 110 degrees. There was no comment regarding gait or reference to hyperextension.  The orthopedist opined that imaging demonstrated long-standing pathology, made a diagnosis of patellar tendonitis, and recommended remedial surgery with protracted rehabilitation be deferred to civilian care after the MEB (CI concurred).  

The 24 November 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, documented that the CI had undergone surgery (arthroscopic debridement of the patella) on 30 June 2008 (4 weeks after separation), and had then suffered a re-injury.  The CI had recovered to the point that he was working two jobs, one requiring prolonged standing.  The examiner noted “intermittent…5/7 days per week” pain rated 5-8/10 that was worsened by sitting, standing, and stair climbing.  The physical examination recorded a “mild” limp without assistive device, tenderness, crepitus, the absence of effusion, and no indication of impingement.  Measured ROM was flexion to 126 degrees (after DeLuca deduction), specifying painful motion, and hyperextension to 20 degrees.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5099-5003 (analogous to degenerative arthritis) cited criteria of the US Army Physical Disability Agency pain policy, but was compliant with VASRD §4.71a criteria for the MEB findings and ROM evidence (via painful motion).  The VA‘s 10% rating under code 5260 (limitation of flexion) was based on the C&P evidence and cited painful motion.  The panel duly considered the mitigation of the probative value of the C&P evidence by the interim surgery and re-injury after separation.

There was no evidence for compensable ROM limitation, persistent effusion and locking, or fracture with nonunion or malunion to support a rating higher than the PEB’s 10% under any applicable code.  Given the functional impairment still present at separation (significant gait disturbance, limitations with standing and walking, etc.), the panel considered analogous rating under code 5299-5262 (tibia and fibula, impairment) which offers ratings for contiguous knee disability: 20% for “moderate” and 30% for “marked.”  Members agreed, however, that the service decision to separate the soldier prior to surgical intervention and rehabilitation was a reasonable one in the above circumstances (as corroborated by the post-separation evidence); thus, analogous rating under a fracture code was not sufficiently justified in this case which satisfies compensable criteria under more applicable codes.  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 of the left knee condition.  
BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20170214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006334, 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