RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01991
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060824

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O3, Signal Officer, medically separated for “posttraumatic arthritis right knee” with a disability rating of 0%.  “Left knee pain” was determined to have existed prior to service (EPTS) and was not rated.  

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 - 20060612	VARD - 20061116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Arthritis Rt Knee	5010	0%	Status-Post Rt Knee Surgery with Osteoarthritis	5260-5003	10%	20060802	
Left Knee Pain	5010	EPTS	Status Post Left Knee Surgery with Osteoarthritis	5260-5003	10%	20060802	
Migraines	Not Unfitting	Migraines	8100	0%	20060802	
Asthma	Not Unfitting	Asthma	6602	10%	20060802	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Posttraumatic Arthritis Right Knee.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right knee surgery on 29 August 2005 for a medial meniscus tear.  

During the 15 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported continued pain, and the knee giving out and locking.  Physical examination noted tenderness of the suprapatellar medial aspect and subpatella.  There was full range of motion (ROM) and pain on flexion.  

The 14 December 2005 MEB NARSUM examination, 8 months prior to separation, noted complaints of difficulties with sustained walking, standing, or sitting in one position for a prolonged period.  Physical examination showed trace effusion, tenderness medially and mild bow-leggedness.  Flexion was to 130 degrees (normal 140) and extension was 0 degrees (normal).  MRI of the right knee showed moderate tricompartmental osteoarthritis and chondromalacia patella.  

At the 2 August 2006 VA Compensation and Pension (C&P) evaluation, 3 weeks before separation, the CI reported pain, weakness, stiffness, fatigue, and lack of endurance.  The CI also reported difficulties navigating stairs, walking and running long distances, or standing for extended lengths of time.  Knee supports were worn daily.  She reported her knee locked every other day.  Physical examination showed a normal gait.  There was mild effusion of the right knee and tenderness.  Flexion and extension were unchanged but painful with motion.  There was no change in ROM after repetitive movement.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5010 (arthritis, due to trauma, substantiated by X-ray findings), citing no ratable limitation of motion.  The VA rated the right knee condition 10%, dual-coded 5260-5003 (leg, limitation of flexion-arthritis degenerative) based on the C&P examination, citing painful or limited motion of a major joint.  

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) 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).  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 applicable in this case, and provided an alternate route to a 10% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition, coded 5010.  

Left Knee Pain.  According to the STR and MEB NARSUM, the CI injured her left knee playing basketball in college and underwent an anterior cruciate ligament (ACL) reconstruction in 1996 prior to entering the service in May 2002.  In 2003 she began having increased knee pain with increased physical activity.  An MRI on 12 May 2005 showed moderate tricompartmental osteoarthritis and postoperative changes compatible with ACL repair.  

During the 15 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported continued pain, knee giving out and locking.  Physical examination noted peripatellar tenderness.  There was no limitation of movement, but there was pain with flexion and extension.  

The 14 December 2005 MEB NARSUM examination, 8 months prior to separation, noted complaints of difficulties with sustained walking and standing or sitting in one position for a prolonged period.  Physical examination showed trace effusion, tenderness medially and mild bow-leggedness.  Flexion was to 115 degrees and extension to -17 degrees.  

At the C&P evaluation the CI reported pain, weakness, stiffness, fatigue, and lack of endurance of her knee.  The CI also reported difficulties navigating stairs, walking and running long distances, or standing stationary for extended lengths of time.  She reported her knee locked every other day.  Knee supports were worn daily.  Physical examination showed a normal gait.  There was tenderness throughout the entire anterior and posterior knee joint.  Flexion was to 120 degrees “out of a possible 130 degrees.”  Extension was normal.  Painful motion was recorded.  There was no change in ROM after repetitive movement.  X-rays revealed osteoarthritic changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the left knee condition was EPTS and not permanently service aggravated (PSA) beyond the natural progression of the condition and was therefore not rated.  The VA rated the left knee condition 10%, hyphenated coded 5260-5003, based on the C&P examination, citing osteoarthritis accompanied by pain on flexion.  

The panel’s first charge was an assessment of the fairness of the PEB’s determination that the condition was EPTS and not PSA.  The panel’s recommendation in that regard was premised on (and the PEB’s decision subject to) DoDI 1332.38 which is excerpted below.  
[E3.P4.5.2.3. Presumption of Aggravation] The presumption that a disease is incurred or aggravated in the line of duty may only be overcome by competent medical evidence establishing by a preponderance of evidence that the disease was clearly neither incurred nor aggravated while serving on active duty or authorized training.  Such medical evidence must be based upon well-established medical principles [E2.2.1 - Fundamental deductions consistent with medical facts that are so reasonable and logical as to create a virtual certainty that they are correct.], as distinguished from personal medical opinion alone. Preponderance of evidence is defined as that degree of proof necessary to fully satisfy the board members that there is greater than a 50% probability that the disease was neither incurred during nor aggravated by military service.
The panel noted the ACL repair prior to service entry.  The CI’s increased activity levels following ACL repair increased the risk for developing osteoarthritis.  Training and military duties are indicative of increased activity level and the injury to the CI’s contralateral knee likely provided additional stresses to the CI’s unfitting left knee condition.  Therefore the panel determined the left knee condition was PSA and eligible for disability compensation.  

The panel then considered its rating recommendation for the unfitting left knee condition at the time of separation.  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 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition, coded 5010.  

Contended PEB Conditions:  Migraines and Asthma. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  The 10 February 2006 neurology examiner noted the headaches did not interfere with her going to work and she lost no time when present for work.  The 26 May 2006 methacholine challenge test refuted the diagnosis of asthma.  There was no performance-based evidence from the record that either 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, the panel recommends a disability rating of 10%, coded 5010 IAW VASRD §4.71a.  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5010 IAW VASRD §4.71a.  In the matter of the contended migraines and asthma 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.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Posttraumatic Arthritis Right Knee	5010	10%	
Left Knee Pain	5010	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010722, 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 and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure