RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02523
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070313

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Healthcare Specialist, medically separated for “chronic pain left knee” with a disability rating of 10%. 

CI CONTENTION:  “What was previously considered a knee injury turned out to be complex regional pain syndrome.”  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 - 20070301	VARD - 20070808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Knee…	5099-5003	10%	...Strain, Left Knee	5299-5257	10%	20070725	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Knee.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee pain began in September 2006 after falling and twisting her knee.  Physical therapy (PT) was recommended.  The CI was given a soft neoprene brace for the knee, but developed a rash and was given a rigid ACL brace.  Knee MRI performed in October 2006 showed a sprain of the lateral collateral ligament (LCL), a partial tear of fibrous tissue of the kneecap (patellar retinaculum) and a possible interstitial tear of the anterior cruciate ligament (ACL).  At an orthopedic follow-up examination on 29 November 2006, physical examination showed active range of motion (ROM) of the knee of 0-110 degrees (normal 0-140).  There was no swelling or effusion (fluid in the knee joint) or tenderness of the joint lines.  There was no medial or lateral instability and no evidence of meniscal pathology (negative McMurray’s test).  There was evidence of anterior laxity with a good endpoint (positive anterior drawer and Lachman’s 2A tests).  Testing for functional instability was negative (negative pivot shift test).  There was quadriceps muscle atrophy as compared to the right.  The orthopedic specialist’s assessment was “Knee sprain:  GR 1 LCL/ACL with a good endpoint on physical examination and improved AROM.”  Despite treatment with crutches, knee brace, medication, profiles, and PT, the CI reported knee pain with all impact activities.  

The 2 February 2007 MEB NARSUM examination, one month prior to separation, noted complaints of ongoing knee pain that prevented physical activity including completing her basic training.  The CI had recently been released from use of crutches.  Physical examination showed a minimally antalgic gait.  There was no swelling or effusion, though the knee was tender in a manner consistent with injury to the lateral (outside) aspect of the knee.  There was no evidence of anterior or lateral instability or meniscal pathology.  Knee ROM (measured by goniometer) was recorded as 0-110 degrees (normal 0-140) after three repetitions, and motion was limited by pain.  Neurologic examination was normal.  At the orthopedic examination on 5 days later, the CI reported improving knee pain, continued participation in PT and use of her knee brace.  Physical examination showed mild atrophy of the left quadriceps muscle, and ROM was recorded as full and pain-free.  There was no medial or lateral instability or evidence of meniscal pathology.  There was evidence of anterior laxity with a good endpoint and pivot shift test was negative.  

During the 25 July 2007 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported constant knee pain, with flares of increased pain along with swelling, that limited walking to one-quarter mile and standing to 30-45 minutes.  She reported a feeling like her knee slid from side to side when not using her brace.  She reported wearing her knee brace for physical activity.  A repeat MRI in April 2007 showed resolution of the LCL sprain, a small effusion, and possible degenerative changes of the ACL.  Physical examination showed a normal gait, with knee tenderness, along with mild laxity but no evidence of meniscal damage.  The examiner recorded ROM as 0-110 degrees, with no pain or change after repetition. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee pain at 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA also rated the left knee at 10%, but coded 5299-5257 (analogous to other impairment of the knee), based on the C&P examination, citing slight recurrent subluxation or lateral instability.  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).  Although the CI was diagnosed with LCL and ACL sprain, there was no evidence of functional impairment related to the mild and variable laxity noted on examinations (ACL at orthopedic examinations prior to separation and side to side laxity noted at post-separation VA examination) to warrant rating under 5257.  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  The panel noted the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating and therefore 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 left knee condition.  

BOARD FINDINGS:  In the matter of the chronic left knee pain and IAW VASRD §4.71a, 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 20190221 and DD Form 294, dated 20170322 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190011717, 

Dear XXXXXXXXXXXXXXXXX:

	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.