RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00597
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20080125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O2, Ordnance Officer, medically separated for “chronic right knee pain” with a disability rating of 20%.  

CI CONTENTION:  Review all conditions.  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 - 20071105	VARD - 20080408	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5257	20%	Internal Derangement with Anterior Cruciate Ligament (ACL) Tear	5299-5262	20%	20071113	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent diagnostic arthroscopy on 8 March 2007.  Although a high tibial osteotomy was planned, the complexity of the internal derangement caused the surgeon to think further about the operative plan and only a debridement of the right medial meniscus was performed.  On 16 May 2007, the CI underwent a high tibial osteotomy (to change the geometry of the knee to maximize stability without any ACL).  Post-surgical knee X-rays showed continued healing, intact surgical hardware and good alignment.  
	
At the 30 August 2007 physical therapy MEB ROM evaluation, knee flexion was 125 degrees (normal 140) and extension was 0 degrees (normal), with painful motion noted.  On instability testing, anterior translation of the knee was noted as “Lachmans: +2 (5-10 mm).”  During the 24 September 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported the need of a knee brace to walk.  The examiner noted the CI may need a knee replacement someday.  

The 3 October 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic right knee pain and instability.  The CI reported that it was painful to walk or climb stairs, with pain aggravated by driving longer than 30 minutes or prolonged periods of sitting or lying down.  There were no complaints of locking or giving way.  Physical examination showed an antalgic gait with right knee tenderness and mild effusion.  Right knee ROM was flexion of 135 degrees and extension of 0 degrees.  There was no evidence of medial or lateral laxity.  Tests for instability revealed some anterior movement with a good end point (2A Lachman’s), but there was evidence of some residual joint instability (positive pivot shift test).  There was no evidence of posterior instability or injury of ligaments of the posterolateral corner (popliteus tendon, popliteifibular ligament and lateral collateral ligament). 

At the 13 November 2007 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported sharp 5/10 right knee pain with occasional swelling, weakness, stiffness, instability and fatigability.  He denied locking and did not claim giving way.  He experienced a flare-up of knee pain daily, lasting 8 hours.  The CI claimed he did not use assistive devices but had a knee brace.  He could walk a half mile but was unable to run and had pain with standing, walking, climbing stairs, squatting, carrying more than 20 pounds, extended driving or riding and sleeping.  Physical examination showed an antalgic gait with tenderness on palpation of the right knee and a positive patellar grind without effusion.  Right knee ROM measurements showed flexion of 110 degrees and extension of 0 degrees, with painful motion noted.  Tests for anterior instability were positive, but the examiner stated the knee was stable laterally and medially.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined four conditions of the right knee forwarded by the MEB as medically unacceptable (right knee osteoarthritis, medial meniscal deficiency, anterior cruciate ligament deficiency and status post high tibial osteotomy) and rated a single unfitting condition of chronic right knee pain 20%, coded 5257 (knee, other impairment of).  The VA also rated the right knee condition 20%, coded 5299-5262, (analogous to impairment of the tibia and fibula), based on the C&P examination, citing X-ray evidence of osteoarthritis with limited painful flexion, atrophy of the right quadriceps, tenderness and patellar deformity which is considered to be a moderate disability.  

The four conditions forwarded by the MEB were all aspects of the right knee condition and their contribution to knee disability could not be separated for individual fitness determinations.  However, the permanent profile listed ACL deficiency and medial arthritis; the commander specifically implicated the profile diagnoses; and, the NARSUM listed all four diagnoses and determined the CI did not meet retention standards for instability, arthritis, pain and chondromalacia.  Therefore, the panel agreed that based on the PEB adjudication, consideration of multiple ratings of the knee IAW VASRD rating guidelines was warranted in this case.  

The PEB assigned a 20% rating for moderate knee impairment due to recurrent subluxation or lateral instability.  There was no evidence of disability due to instability that could be characterized as “severe” at the time of separation to warrant the next higher rating of 30%.  At the MEB NARSUM and pre-separation VA examinations the CI was not using an assistive device.  He did not report any disabling symptoms of instability, such as giving way of the knee, following the high tibial osteotomy, despite the finding of persistent ACL laxity on clinical examination, as would be expected since the ACL was not repaired.  He did use an off-loader type knee brace, which would provide stability to the knee, but also functioned to reduce pain due to the healing surgical site and advanced degenerative changes in the knee.  There was no evidence of nonunion or malunion of the tibia following the osteotomy with grafting for rating under 5262 (tibia and fibula, impairment of).  Even if rated analogously to 5262, by the same reasoning noted above regarding 5257, there was no evidence of severe disability, despite the multiple abnormalities within the knee.  At both the MEB NARSUM and VA examinations the CI reported knee pain, but denied locking or giving way; at the pre-separation VA examination he reported occasional swelling.  Good ROM of the knee, within functional limits, was noted at both examinations.  There was insufficient limitation of motion of flexion and/or extension to support a rating under either of those codes (5260, 5261).  There was no ankylosis or impairment of the femur with marked knee disability for a higher rating under those codes (5256, 5255).  

The panel next deliberated the application of dual ratings according to VASRD guidelines, based on separate ratings for instability and painful motion due to degenerative changes.  There was no evidence of sufficient limitation of flexion or extension to consider any more than two ratings for the knee.  The painful knee motion would warrant a 10% rating under 5003 or 5299-5260 IAW VASRD 4.59 (painful motion) and the panel agreed that the instability noted at separation, when considered alone, would warrant a 10% rating for “slight” knee disability under 5257.  As discussed above for rating under 5257, the primary focus of the CI’s complaints at the MEB NARSUM and VA examinations was knee pain and swelling and not instability related symptoms.  So although the PEB assigned a 20% rating under the 5257 code for all the contributions to the knee disability, when reasoned out under separate rating codes, the panel did not arrive at a higher combined rating recommendation for the knee.  Thus, this approach did not result in a ratings benefit to the CI.  No higher rating than a 20% rating was supported for the knee at separation and therefore no change to the PEB adjudication of the right knee condition is recommended.  After due deliberation, considering all of 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 right knee condition.  

BOARD FINDINGS:  In the matter of the right 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 Treatment Record 

AR20180004713, 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