JRRECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03391
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080708

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Food Service Operator, medically separated for “left knee pain and osteoarthritis” with a disability rating of 10%.   

CI CONTENTION:  “Fractured tibial plate retaining hardware. Future total knee replacement pending.”  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 - 20080501	VARD - 20080124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain and Osteoarthritis	5010	10%	Left Knee Degenerative Changes and Left Knee Patellar Tendonitis, Status Post Left Plateau Fracture	5299-5010	10%	20070129	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Knee Pain and Osteoarthritis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in May 2000 when he sustained a valgus type stress event to his left knee injuring the medial collateral ligament and fracturing his lateral tibial plateau.  The CI underwent surgery for left lateral meniscus repair and ORIF (open reduction and internal fixation) of a lateral tibial plateau fracture.  In May 2003, the CI was found to be unfit for enlistment into the National Guard secondary to left knee retained hardware.  In May 2004, the CI was granted a medical waiver and he joined the National Guard.  During pre-deployment activities, the CI reported left knee pain.  In August 2006, the CI was cleared for deployment and deployed to Kuwait.  Shortly after arriving in theater, the CI reported left knee pain and swelling with walking and wearing his Kevlar vest and helmet.  The CI was redeployed.  

At the 29 January 2007 VA Compensation and Pension (C&P) examination, 18 months prior to separation, the CI reported knee pain, weakness, stiffness, swelling, fatigability, lack of endurance,  and some instability, but no giving way or locking.  He denied dislocation or recurrent subluxation.  He reported flare-ups two to three times per week for the day.  During flares he reported difficulty walking, going up stairs, or standing for long periods of time.  He denied use of an assistive device for ambulation.  Physical examination (PE) showed a normal gait.  Left knee flexion was 120 degrees (normal 140) and extension was 0 degrees (normal) with facial grimacing and guarding as objective evidence of painful motion.  The CI was only able to perform two repetitive motions due to pain.  There was mild laxity of the medial collateral ligament testing for instability.  Meniscal pathology was negative.  Pain was noted with all testing.  

The 30 October 2007 VA orthopedic examination, 8 months before separation, the CI reported pain with intermittent periods of knee “buckling.”  On August 2007, the CI had undergone an open arthrotomy to remove the plate, but fixation screws were retained.  The hardware removal did not provide relief of his symptoms.  Knee pain was worse with stairs.  A PE showed tenderness with no effusion.  Knee range of motion (ROM) was flexion at 135 degrees (normal 140) with terminal flexion/extension pain.  There was no crepitus but there was laxity of the anterior cruciate ligament with a firm end point (Lachman’s Grade 2A) and there was lateral collateral ligament laxity.  

During the 15 February 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, PE showed tender medial and lateral joint lines.  Medial and lateral collateral ligaments were very lax.  Patellar grind was positive and there was tenderness lateral to the patella.  There was quadriceps muscle atrophy on the left as compared to the right.  Knee ROM was measured by physical therapy on 26 February 2008 and flexion was 130 degrees and extension was 0 degrees after repetition, with limitation due to pain.  

The 3 March 2008 MEB NARSUM examination, 4 months prior to separation, noted the CI reported he was unable to fully weight bear, kneel, ascend or descend stairs comfortably, and he reported a sensation of giving way.  The CI ambulated with a cane.  A PE showed a moderate to severe antalgic gait.  There was no obvious deformity of the left knee but diffuse moderate edema with decreased tone of the left quadriceps muscles was visible.  There was pain and stiffness with flexion to 135 degrees (normal 140) and peripatellar tenderness.  There was laxity of the medial collateral ligament and no anterior or posterior laxity or instability.  A previous January 2007 left knee CT scan and X-rays on 28 February 2008 showed degenerative changes of the knee and patellofemoral joints.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee and osteoarthritis condition 10%, coded 5010 (arthritis, due to trauma) citing functional loss due to factors such as pain, including painful motion, fatigability incoordination, weakness with repetitive use, and flare-ups.  The VA also rated the left knee degenerative changes and left knee patellar tendonitis condition 10%, analogously coded 5299-5010 (arthritis, due to trauma), based on the C&P examination, 18 months prior to separation, citing 10% for painful or limited motion of a major joint.  Later VA Rating Decisions assigned a 100% rating for the period of convalescence following the surgery for hardware removal in August 2007, but returned to the 10% rating at the end of convalescence effective 1 April 2008.  

The panel noted 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) to support a rating under that code.  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  

The panel noted that the CI residual knee disability was due in significant part to a fracture of the tibia requiring ORIF and therefore also considered a rating coded analogous to 5262 (tibia and fibula, impairment).  The panel agreed a 20% rating was supported for moderate knee disability based on swelling, tenderness, antalgic gait, and use of a cane with anterior and lateral laxity and decreased muscle tone.  There was no evidence of marked disability to support a 30% rating such as significant severe, swelling, muscle atrophy, weakness, and/or greater limitation of knee ROM.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left knee condition, coded 5299-5262.  

BOARD FINDINGS:  In the matter of the left knee pain and osteoarthritis condition, the panel recommends a disability rating of 20%, coded 5299-5262 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	
Left Knee Pain and Osteoarthritis	5299-5262	20%	

The following documentary evidence was considered:

AR20190008560, 

Dear XXXXXXXXXXXXXXXX:

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.