RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02292
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030406

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cable Systems Installer/Maintainer, medically separated for “chronic right anterior knee pain with associated mild patellar instability” with a disability rating of 0%.  

CI CONTENTION:  She wanted to stay in the Army and still has issues with her knee and ankle.  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 - 20020920	VARD - 20030421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Anterior Knee Pain with Associated Mild Patellar Instability	5099-5003	0%	Right Knee Patellar Instability	5257-5024	10%	20030122	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Chronic Right Anterior Knee Pain with Associated Mild Patellar Instability.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right knee condition began in July 2001 after running.  Seven years earlier the CI had a fracture of the tibia with placement of a plate and screw, which was removed in the same year.  An MRI dated 26 September 2001 demonstrated evidence of a tear (parrot beak) of the anterior horn of the lateral meniscus, a possible tear (likely degenerative) of the posterior horn of the medial meniscus, and evidence of probable partial tear versus possible strain of the proximal to mid-aspect of the posterior cruciate ligament.  Orthopedic examination on 6 December 2001 revealed range of motion (ROM) of 10-140 degrees (0 to 140 normal) with a positive grind test, medial joint line tenderness, and a tender medial plica.  At an orthopedic visit on 9 January 2002 the orthopedic surgeon felt the CI’s symptoms were from the medial plica, not meniscal.  She was given a steroid/anesthetic injection to the plica.  Three weeks later the CI reported no relief from the injection and she still had pain with activity.  Ultrasound was recommended to be added to the treatment protocol.  Patellar instability was noted and the CI was given a brace, which provided moderate patellar control.  She was felt to be a poor operative candidate.  

An MRI of the right knee dated 2 July 2004 showed minimal knee joint effusion.  The medial and lateral collateral ligaments were intact and there was no more than mild or minimal osteoarthritis involving the knee.  The patellofemoral joint relationships were normal.  No cartilage degeneration, injury, or chondromalacia were seen, although the radiologist noted those conditions are often not visible by MRI.  The anterior and posterior cruciate ligaments were intact and no meniscus tear was noted.  The radiologist opined that cartilage degeneration or pathologies could certainly be present.  

During the 12 June 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 10 months prior to separation, the CI reported right knee pain.  The examiner checked lower extremities abnormal in the clinical evaluation and listed right patella instability in the summary of defects and diagnoses.  

The 20 August 2002 MEB NARSUM examination, 8 months prior to separation, described her pain as medial peripatellar pain, with occasional diffuse pain and lateral pain as well.  She had received the diagnosis of patellar instability as the likely etiology of her pain.  Physical examination showed a normal gait without a limp.  The ROM of the right knee was from 10 degrees recurvatum (normal extension 0) to 140 degrees of flexion (normal 140).  There was no effusion.  She had a tender medial plica, tender medial joint line, and no lateral joint line tenderness.  Her patella was hypermobile with three quadrant lateral mobility with associated apprehension.  There was good quadriceps bulk and tone.  McMurray’s test (to determine a meniscal tear) was negative and she could duck walk without difficulty.  She had a negative Lachman’s test (to determine an injury to the anterior cruciate ligament (ACL)), no pivot shift (to determine an ACL injury), and no varus or valgus laxity.  The examiner noted 4/4 signs of generalized ligamentous laxity.  

At the 22 January 2003 VA Compensation and Pension (C&P) examination, less than 3 months before separation, the CI reported constant pain of the right knee and denied dislocation, subluxation, inflammatory arthritis, and prosthesis, although she used a knee brace, Ben-Gay, and Tylenol.  Physical examination showed a normal posture and gait.  The right knee was tender and there was pain with McMurray’s test.  Flexion was 140 degrees with pain.  Fatigability and pain as well as weakness were noted with repetitive use.  The examiner’s diagnosis was right knee patellar instability.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right anterior knee pain with associated mild patellar instability condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the U.S. Army Physical Disability Agency pain policy.  The VA rated the right knee patellar instability condition 10%, dual coded 5257-5024 (knee, other impairment of:  recurrent subluxation or lateral instability-tenosynovitis) based on the C&P examination, citing a full ROM with evidence of pain on motion during ROM testing.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examination most proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257).  Although there was three quadrant laxity of the right patella at the NARSUM examination, no findings of patellar instability were reported at the VA examination which was more proximate to separation.  There was no history of a 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 the respective codes.  There was no fracture, non-union, 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) at the VA examination.  

Panel members noted that the PEB indicated the diagnosis of chronic right anterior knee pain with associated mild patellar instability thereby raising the question of whether the mild patellar instability was in the scope of review.  It was neither explicitly requested to be reviewed nor was it implicit in the CI’s contention.  Furthermore, as noted above, patellar instability was the likely etiology of her knee pain.  Therefore, in the absence of a determination of patellar instability as a separately unfitting condition, an additional rating for patellar instability is not applicable in this case.  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 chronic right anterior knee pain with associated mild patellar instability condition, coded 5099-5003

BOARD FINDINGS:  In the matter of the chronic right anterior knee pain with associated mild patellar instability 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 the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Anterior Knee Pain with Associated Mild Patellar Instability	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170409, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008659, 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