RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01675
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090304

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Infantryman, medically separated for “right knee pain” with a disability rating of 10%.  

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 - 20081110	VARD - 20090811	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	S/P ACL Repair and Removal of Most of the Medial Meniscus, Right Knee	5260	10%	20090422	
Hearing Loss Left Ear with Bilateral Tinnitus	Not Unfitting	Tinnitus	6260	10%	20090422	
		Left Ear Hearing Loss	6100	0%	20090422	
Gunshot Wound Neck and Right Trapezius, Superficial no Limitations	Not Unfitting	Multiple Superficial Gunshot Wounds, Back	7802	0%	20090422	
Low Back Pain	Not Unfitting	Back Condition with a Decrease in Height	5237	NSC	20090422	
Anger Issues Related to his Medical Condition	Not Unfitting	Anxiety Disorder	9413	30%	20090422	
Bilateral Elbow Pain	Not Unfitting	Right Elbow Condition	5206	NSC	20090422	
Right Torso Pain, Intermittent	Not Unfitting	Dislocated Left 7th Rib at the Intercostal Junction	5299-5297	0%	20090422	
Dust Mite Allergies	Not Unfitting	Allergies	6522	NSC	20090422	
Left Knee Pain	Not Unfitting	Left Knee Condition	5257	NSC	20090422	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	
ANALYSIS SUMMARY:  

Right Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI had two right knee surgeries in 1995, 9 years prior to enlistment in 2004, for a partial meniscectomy, and a complete anterior cruciate ligament (ACL) tear and patellar graft repair.   Throughout training and deployment he had minimal to no pain until March 2007 when he injured his knee while doing a squat.  He continued combat missions, but had significant pain.  In June 2007 a posterior horn medial meniscal tear and status post ACL repair with an intact graft with no evidence of impingement was demonstrated by MRI dated 14 June 2007.  On 20 June 2007, the CI underwent debridement and postoperative physical therapy (PT) with good results.  He deployed again and noted in December 2007 that he could not run or perform impact activities.  Examination revealed a range of motion (ROM) of 0-135 degrees (normal 0-140) and a positive McMurray’s test (to determine a meniscal tear).  

On 29 February 2008, the CI underwent a partial medial meniscectomy of posterior horn and postoperative PT thereafter.  By 20 March 2008 the CI had regained almost all right knee motion and on 16 July 2008 his right knee ROM was 0-135 degrees and McMurray’s and Lachman’s (to determine laxity) tests were negative.  

The 14 October 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of daily right knee pain, weakness, and instability.  Physical examination showed a mildly antalgic gait favoring the right.   The CI was able to rise from a seated position on the examination table without difficulty.  There was no effusion or tenderness; however, there was mild retropatellar crepitus (grinding sensation). There was “near full active range of motion with some pain at full flexion.”  A  McMurray's test was positive and a Lachman's test was negative.  

The 20 October 2008 PT examination, 5 months prior to separation, showed the right knee ROMs following repetitive motion were flexion of 142 degrees and extension of -1 degree (normal 0).  A Lachman’s test was +1 with a negative McMurray’s test.  The examiner noted the CI’s “pain complaints and limitation were not represented with ROM.  It is likely that deficits would be seen with running or other functional activities.” 

At the 22 April 2009 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported pain, instability, giving way, and some locking.  Physical examination showed a normal gait and the right knee had a deformity, swelling, tenderness medially, and crepitus, but no laxity.  The right knee flexion was 135 degrees and with normal extension but pain.  X-ray evidence showed orthopedic hardware from the prior ACL repair and no significant degenerative changes were noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing consideration given to VASRD §4.10 (functional impairment) and §4.40 (functional loss).  The PEB also noted the right knee was a preexisting condition “but the presumption of permanent service aggravation is not overcome.”  However, the PEB did not deduct for the preexisting condition since the EPTS factor was undetermined.   The VA also rated the right knee condition 10%, coded 5260 (limitation of flexion), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.

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).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  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).  Therefore, there was no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 right knee condition.  

Contended PEB Conditions:  Left Ear Hearing Loss with Bilateral Tinnitus; Neck and Right Trapezius Gunshot Wounds; Low Back Pain (LBP); Anger Issues; Bilateral Elbow Pain; Right Torso Pain; Dust Mite Allergies; and Left Knee Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The hearing loss was profiled as H2, which indicates an individual possesses some medical condition or physical defect that may require some activity limitations.  None of the other conditions were profiled, implicated in the commander’s statement, or judged to fail retention standards. 

Left Ear Hearing Loss with Bilateral Tinnitus.  In March 2005 the CI had an average hearing loss on the left of 23.75 dB and an average loss of 7.5 dB on the right.  On 5 May 2008, at an otolaryngology visit, the CI was noted to have sensorineural hearing loss, left greater than right.  Examination showed an external auditory canal 2 mm skin lesion.  The tympanic membrane was normal as was its mobility.  Tinnitus was noted to be subjective.  At an audiology visit on 5 May 2008 options for a hearing aid were discussed and one was ordered.  At the VA C&P audiology examination the CI average hearing loss on the left was 31.25 dB and on the right 7.25dB.  Speech recognition scores were 94% for the left ear and 100% for the right ear.  Results of tympanometry, acoustic reflex testing, and acoustic reflex decay were unremarkable.  

Neck and Right Trapezius Gunshot Wounds.  The CI was hit by sniper fire on 11 January 2007 and the bullet struck near the top of a SAPI (small arms protective insert) plate and traveled down his torso, but did not penetrate deeply.  Three small lacerations were cleaned and dressed, and anti-inflammatory medication and muscle relaxers were prescribed.  

LBP.  The CI reported falling 15 feet during basic training while climbing a rope.  X-rays of the lumbar spine in December 2004 showed superficial endplate compression fractures, while X-rays of the hip joints were normal. The CI underwent PT and chiropractic therapy through 28 October 2008.  X-rays of the lumbosacral spine dated 14 April 2009 showed no fracture or dislocation.  

Anger Issues.  The CI had visits to the mental health clinic 6 months after a 15-month deployment.  He wanted to get back to his “old self.”  He reported a low tolerance and irritability level and other stressors.  He worked on stress management techniques.  Mental status findings on 11 June 2008 revealed the CI’s mood was frustrated and affect was full-ranging.  The remainder of the examination was normal.  After a return from leave, he reported marked improvement with his anger issues and continued to work on reframing and stress management techniques.  A 25 July 2008 mental status examination was normal.  A 2 December 2008 note based on a records review indicated the CI did not have any follow-up visits after July 2008.  The reviewer’s assessments included anxiety disorder NOS, partner relational problem, and occupational problem. His Global Assessment of Functioning score was 70 (some mild symptoms).  

Bilateral Elbow Pain.  The CI reported he injured his right elbow during combat training in January 2006 and the left elbow in June 2006.  X-rays of the right elbow were negative.  At the C&P examination, the right elbow was normal with a ROM of 0-150 degrees with pain.  The right and left elbows had no flare-ups.  

Right Torso Pain.  The CI fell 15 feet while climbing a rope during physical training on 10 December 2004.  X-rays of the thoracic spine were normal on 10 December 2004 and again on 17 December 2004.  A note dated 13 February 2006 indicated the CI was punched in the ribs during combatives and had pain and point tenderness on the right.  The assessment was a contusion with intact skin on the surface of the right chest wall.  Treatment consisted of naproxen (an NSAID). An abdominal X-ray was normal with some widening of the 10th rib on the right side in the area of the deformity without a fracture or other abnormalities noted.  X-rays of the thoracic spine and ribs on 14 April 2009 were normal.  

Dust Mite Allergies.  A 8 September 2004 note indicated “Bromfed for dust mite allergies.”  On 14 September 2004 loratadine (an antihistamine) and fluticasone (a steroid) nasal spray were prescribed for allergic rhinitis-dust mite.  

Left Knee Pain.  On 24 April 2008 the CI complained of a rash of the left knee from a possible spider bite that “hurts like hell” for 72 hours.  Examination revealed a single pustule that was painful, erythematous, and circular in shape on the anterior left knee; it had developed rapidly and was enlarging.  Treatment consisted of clindamycin, an antibiotic.  On 28 May 2008, the CI reported left knee pain for 2 weeks in the patellofemoral region, which was worse with twisting, squatting and use of stairs. There was tenderness at the iliotibial band insertion and pain with valgus stress, otherwise the knee was stable.  The examiner’s assessment was iliotibial band syndrome.  Treatment consisted of piroxicam, an NSAID.  X-rays of the left knee dated 22 April 2009 showed the bones and soft tissues of the left knee area had a normal appearance.  There was no shrapnel, soft tissue calcifications, or degenerative joint disease.  

There was no performance-based evidence from the record that any of the 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left ear hearing loss with bilateral tinnitus, neck and right trapezius gunshot wounds, LBP, anger issues, bilateral elbow pain, right torso pain, dust mite allergies, and left knee pain 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 20170213, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

	

AR20180010939, 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