RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01881
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Trainee, medically separated for “periarticular pathology left knee with possible osteochondral lesion of the lateral tibial plateau” with a disability rating of 10%.  

CI CONTENTION:  The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20081024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Periarticular Pathology Left Knee with Possible Osteochondral Lesion of the Lateral Tibial Plateau	5099-5003	10%	Residuals, Lateral Tibial Plateau Fracture (Bone Contusion) & Osteochondral Defect, Lateral Femoral Condyle, Left Knee, w/ Limited Motion	5010	10%	20080908	
			Residuals, Lateral Tibial Plateau Fracture (Bone Contusion) & Osteochondral Defect, Lateral Femoral Condyle, Left Knee, w/ Laxity and Instability	5010-5257	10%	20080908	
Adjustment Disorder	Not Unfitting	Anxiety Disorder NOS	9440	30	20080926	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Periarticular Pathology Left Knee with Possible Osteochondral Lesion of the Lateral Tibial Plateau.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in October 2007 after a traumatic hyperextension injury in basic training.  The CI reinjured his left knee in January 2008 with a twisting injury when he ran into a hole.  Left knee MRI on 31 January 2008 showed bony lesions of the tibial plateau with bone marrow edema.  There was no indication for surgery.  

The 12 February 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of left knee pain with decreased motion and instability.  Physical examination showed the CI was ambulating with crutches for partial weight bearing of his left leg.  There was a mild left knee suprapatellar effusion with no patellar tilt or laxity.  There was mild crepitation on straight leg raise with active range of motion (ROM) limited by pain to 113 degrees (normal 140) and extension to 5 degrees (hyperextension; normal 0 degrees).  There was no laxity or instability (“The exam is stable demonstrating a negative Lachman’s, negative drawers.  …There is no laxity with valgus or varus stressing…”).  There was joint line tenderness.  X-rays showed minor degenerative changes of the left knee.  

At the 3 September 2008 VA orthopedic consult, 3 months after separation, the CI complained of constant left knee pain with a sensation like the knee may give way.  He used a knee sleeve‑type brace that was somewhat helpful.  Examination revealed an antalgic gait.  There was left knee tenderness without effusion.  ROM was flexion to 115 degrees and hyperextension to 5 degrees.  Regarding instability, the examiner stated:  “The knee appears stable to varus and valgus stress….There is anterior drawering of approximately 8-10 mm, Lachman’s test 0-1+.   Lachman's and anterior drawer are equal to the right knee.”  

At the 8 September 2008 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported constant left knee pain with swelling on (prolonged) standing.  He also reported use of a brace and cane for walking, stiffness, weakness, giving way, and instability of the left knee.  Physical examination showed an antalgic gait.  The left knee was tender and ROM was painful with flexion to 140 degrees and extension to 5 degrees.  There was no crepitus, instability, or grinding.  

The 6 February 2009 VA orthopedic progress note, 8 months after separation, documented continuing complaints of left knee pain without mention of instability symptoms.  Examination revealed an antalgic gait.  The CI was able to heel- and toe-walk.  Left knee ROM was +5-125 degrees (normal 0-140) with 0-1+ effusion and tenderness.  The knee was stable and Lachman’s test was negative for laxity.  MRI from 22 December 2008 showed “no significant abnormality demonstrated.”  

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 ROMs with no evidence of instability and painful motion with rating IAW VASRD §4.59 (painful motion).  The VA rated the left knee condition 10%, coded 5010 (arthritis due to trauma), and 10%, dual coded 5010-5257 (5010 – knee, other impairment of: recurrent subluxation or lateral instability), based on the C&P examination and VA consult, citing painful or limited motion, and a positive drawer sign with reported instability, respectively.  

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), or history of surgery to remove a meniscus (5259), to support a rating under those codes.  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).  

The panel noted that the PEB considered instability in its adjudication and rendered a de facto “not unfitting” determination by explicitly stating “no evidence of ligamentous instability,” and the CI reasonably contended this condition.  However, the STR examinations and C&P examination documented no ligamentous laxity or instability.  The September 2008 VA orthopedic consult was the single VA examination proximate to separation documenting any ligament laxity and it demonstrated no greater laxity than in the contralateral knee.  There was insufficient evidence that the CI had any unfitting instability of the left knee for additional rating.  There was therefore no higher rating than 10% available under any applicable VASRD 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 left knee condition.  

Contended PEB Condition:  Adjustment Disorder.  Adjustment disorder was a condition not constituting a physical disability, IAW DoDI 1332.38, in effect at the time of separation.    Therefore, the panel has no basis for recommending it as unfitting.  The panel concluded there was insufficient cause to recommend a change in the PEB determination for the contended adjustment disorder condition, so no additional disability rating is 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 adjustment disorder condition, the panel agrees it cannot recommend it for additional disability rating.  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 20170313, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008648, 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.

	A copy of this decision has also been provided to the counsel you listed on this application, XXXXXXXXXXXXXXXXXX

Sincerely,					      
Enclosure