RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02517
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050610

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a  National Guard E4, Infantryman, medically separated for “chronic right knee pain” with a disability rating of 20%.  

CI CONTENTION:  Review requested of knee disability rating and a scar that was not considered.  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 USPDA - 20050324	VARD - 20060124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5009-5003	20%	Residual of Right Knee Injury, Meniscal Tear	5259	10%	20050826	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic right knee pain began while deployed to Bosnia where he sustained several different injuries (blow to the medial aspect of the right knee; landing wrong on the right knee during a helicopter dismount; and continuation of training and PT activities).  Following demobilization, an MRI showed osteochondral defects (OCD) of the lateral femoral condyle and tibial plateau, and he underwent right knee arthroscopy on 25 November 2003 for debridement and OCD repair.  He had a second surgery on 1 September 2004 for cartilage implant followed by rehabilitation.  At an orthopedic follow-up visit, range of motion (ROM) testing showed flexion to 110 degrees (normal 140) and extension to 0 degrees (normal).  There was effusion, but no instability, and the CI was to be non-weight bearing for 4 more weeks.  

The 29 October 2004 MEB NARSUM examination, 9 months prior to separation, noted the CI was still in rehabilitation and non-weight bearing on the right with crutches and a hinged brace.  Physical examination was completed without removal of the brace, and he was able to extend his knee in the sitting position, but had great difficulty and pain when the knee hung down at 90 degrees.  There was mild medial and lateral joint effusion and tenderness.  Flexion was to 55 degrees, with pain beginning at 35 degrees and measurements beginning at 10 degrees in flexion with the hinged brace.  

The 22 March 2005 MEB addendum, 3 months prior to separation, noted CI complaints of constant knee pain and “popping,” and the ability to only partially bear weight.  He was still in physical therapy, used a cane to ambulate, and occasionally wore his knee brace.  Physical examination showed a well-healed surgical scar, slight quadriceps atrophy, mild crepitus with movement and minimal effusion.  Tenderness was noted along the medial, lateral and inferior patellar margins.  There was no evidence of instability, but testing caused pain.  Knee ROM measured with a goniometer showed flexion to 80 degrees, with increasing pain beginning at 60 degrees.  Gait was antalgic, favoring the right leg.  

At the 26 August 2005 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported chronic pain and discomfort beneath the lower aspect of the patella, with occasional popping but no swelling; he was able to ambulate with assistive devices.  Physical examination showed no swelling, deformity, instability or meniscal injury.  Quadriceps muscle strength was good, and knee ROM was from 0-140 degrees, with no ROM change, fatigue or increased pain after three repetitions.  

During an outpatient VA orthopedic visit on 27 October 2005, the CI reported persistent right knee pain aggravated by walking, kneeling and stairs.  Physical examination showed no effusion, but there was tenderness over the medial joint line and pes bursa (located below the patella medially).  Testing for meniscal pathology was positive medially with no evidence of instability.  An MR arthrogram performed on 22 November 2005, showed degenerative changes, a small tear in the lateral meniscus, and a defect of the lateral femoral condyle that was suspicious for focal osteonecrosis or OCD.  At a VA orthopedic follow-up on 14 February 2006, 8 months after separation, physical examination showed right knee flexion of 130 degrees and extension of 0 degrees.  The knee was stable, but there was pain of Hoffa’s fat pad which increased with compression and terminal extension.  Fibrosis of the retropatellar fat pad was suspected and an arthroscopy was planned.  

The panel directed attention to its rating recommendation based on the above evidence.  The US Physical Disability Agency (USAPDA) rated the chronic right knee pain 20%, analogously coded 5003 (degenerative arthritis), citing the USAPDA pain policy.  The VA rated “residual of right knee injury, meniscal tear” 10%, coded 5259 (cartilage, semilunar, removal of, symptomatic) based on the C&P examination and VA outpatient treatment records, citing cartilage damage with no decrease in ROM.  Members noted that the examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  Additionally, 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).  The panel agreed there was no evidence to support a rating higher than that adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  Members noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating, and no change to the PEB’s coding choice is recommended.  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 chronic right knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic right knee pain and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  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 20170314, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20190007823, 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