RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01228
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20070128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Chemical Operations Specialist, medically separated for “left knee pain” with a disability rating of 0%.  

CI CONTENTION:  He was given a higher rating for his conditions by 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 - 20070108	VARD - 20070609	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	0%	Instability, Left Knee	5257	20%	20070412	
			S/P Arthroscopy, Left Knee with Residual Scars	5260-5014	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee pain condition began in November 1999 after an injury in basic training and re-injury in August 2003.  The CI had two arthroscopic surgeries in January 2004 and July 2005 to repair an anterior cruciate ligament tear, meniscal tear, and to remove a Baker's cyst with continued pain complications.  CI was a member of the National Guard and received his first VA rating decision for left knee pain in June 2006, 7 months prior to separation, and an updated VA rating decision in June 2007, 5 months post separation.  
At the 2 May 2006 VA Compensation and Pension (C&P) examination, 9 months before separation, the CI reported continued left knee weakness, stiffness, swelling, giving way, and locking.  The pain was constant (aching, cramping, sharp) with no radiation of pain.  He was unable to run, jump, kneel, stand, or sit for an extended period of time.  He was able to function without medication and had two periods of incapacitation per week.  Physical examination showed a mildly antalgic gait and no evidence of clicking sound (crepitus), edema, effusion, tenderness, redness, heat, or guarding of movement.  Active range of motion (ROM) was painful with flexion of 90 degrees (normal 140) and extension of 0 degrees (normal 0).  On repetition ROM was additionally limited by pain, weakness, fatigue, lack of endurance, and instability with pain having the major functional impact, with no further loss of degrees.  Radiographic (X-ray) image of the left knee showed no significant findings.  

At the 18 October 2006 MEB NARSUM examination, 3 months prior to separation, the CI complained of continued left knee pain and that he had not regained full ROM.  Physical examination showed “full” active and passive ROM (no degrees noted).  There was tenderness to palpation along the medial retinaculum.  

At the 12 April 2007 VA C&P examination, 3 months after separation, the CI reported weakness, stiffness, swelling, giving way, and lack of endurance with prolonged standing and walking.  The pain was described as crushing, squeezing, burning, aching, oppressing, sharp, and cramping in nature.  The CI was able to function without medication, the pain was not incapacitating, and he was not receiving treatment for the pain.  Physical examination showed tenderness, abnormal movement, and guarding of movement with no recurrent subluxation, locking pain, joint effusion, or crepitus.  Active ROM was painful with flexion of 90 degrees and extension of 3 degrees.  There was increased pain, fatigue, weakness, and lack of endurance after repetition.  Stability tests of the knee showed instability with the anterior and posterior cruciate ligaments and medial and lateral collateral ligaments.  The medial and lateral meniscus test was abnormal with a moderate degree of severity.  X-ray image of the left knee showed no significant findings.  

During the 28 August 2007 VA internal medicine clinic examination, 7 months after separation, the CI reported his “knee is much better, working out and jumping” with no problem and “wants to be released to go back to military as doing well.”  The examiner requested an MRI, and results showed minor abnormalities with minimal joint effusion and Baker’s cyst; mild degenerative changes of the medial compartment; and all ligaments, menisci, patella, and tendons intact.  

At the 14 September 2007 VA internal medicine clinic examination, 8 months after separation, the examiner reported the knee MRI was very good and showed minimal arthritis with ligaments, patella, and tendons intact.  The examiner wrote a memo on behalf of the CI indicating his knee condition was cleared for the CI “to go back and join the military if he wishes.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee pain condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing “rated for pain, slight/intermittent,” with likely application of the US Army Physical Disability Agency pain policy.  The VA rated the left knee pain condition 10%, coded 5260-5014 (leg, limitation of flexion - osteomalacia), based on the C&P examination 8 months prior to separation, and again 10% based on the examination 5 months after separation, citing painful or limited motion of a major joint on each rating.  

The panel deliberated on the probative value of the examinations in evidence.  Both the VA examinations before and after separation documented painful motion.  The intervening MEB examination was the single examination documenting full ROM, but did not specify degrees of ROM or address repetition or painful motion.  However, it did document tenderness and subjective symptoms that had a nexus to the CI’s prior meniscal surgery.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was also analogously applicable in this case, and provided an alternate route to a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee pain condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the left knee pain condition, the panel recommends a disability rating of 10%, coded 5099-5003 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170217, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180004937, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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