RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-03577
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070820

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Infantryman, medically separated for “left knee injury resulting in complete tear of anterior cruciate ligament (ACL) and partial tears of the posterior cruciate ligament and the meniscus” with a disability rating of 20%.

CI CONTENTION: The left knee injury made employment challenging. Additionally, dealing with post-traumatic stress disorder, traumatic brain injury, and memory issues. 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 - 20070629	VARD - 20080702	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Injury…	5257	20%	Left Knee Meniscal Tear	5299-5259	10%	20080304	
Migraine Headaches	Not Unfitting	Headaches, Post-Concussion Syndrome	8045-8100	0%	20080304	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 20%	
	
ANALYSIS SUMMARY:

Left Knee Injury. According to the MEB NARSUM and service treatment record the CI underwent ACL reconstruction and partial meniscal removal in January 2005. A postoperative left knee MRI revealed an absent ACL resulting in a second ACL reconstructive surgery in April 2006. After the second surgery, left knee MRI revealed an intact but loose ACL graft and a meniscus flap that interfered with normal knee rotation.         In January 2007, she underwent a left knee ACL graft

debridement and meniscal debridement. Orthopedic follow-up documented continued laxity of the left knee. A third ACL reconstructive surgery was discussed, but the CI reasonably declined.

A physical therapy examination on 24 April 2007, 4 months before separation, noted complaints of increased left knee pain with the inability to run. Physical examination showed a nonantalgic gait with positive left knee instability. Knee flexion and extension were “normal.” Painful motion was not addressed. Orthopedic examinations on 26 April 2007 and 1 June 2007 noted complaints of left knee pain. Physical examinations revealed a normal gait. There was mild swelling. Instability testing showed some anterior translation with a firm endpoint (2A Lachman) and greater anterior laxity on the left than the right (a positive anterior drawer) with a negative pivot shift test (tests functional instability). Patellofemoral grind test was negative. Knee flexion and extension were “normal.” There was positive testing for meniscal pathology (painful motion).

During the 19 June 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported knee problems, surgery, and use of a brace. He reported his knee was “still loose.” Physical examination showed pain with knee flexion and extension and a “Lachman 2” was noted. At the MEB NARSUM examination on the same day, the CI reported left knee pain and instability. Physical examination showed mild left knee swelling. There was no tenderness or muscle spasm. Instability testing showed some anterior translation with a firm endpoint and greater anterior laxity on the left than the right (a positive anterior drawer) with a negative pivot shift test. Patellofemoral grind test was negative. Testing for meniscal pathology was positive (painful motion). Repetitive knee flexion was 100 degrees (normal 140) and extension was 0 degrees (normal) with painful motion elicited.

At the 4 March 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported left knee pain, weakness, stiffness and give way. The CI reported he had a brace, but it did not help him and he was unable to exercise in the brace. He could run a quarter mile in the brace, but there was no limitation of walking in the brace. He reported he did not wear the brace very often and did not use a cane or a crutch. He was not currently taking any prescription medication for the knee because he ran out. Physical examination showed a normal gait. Left knee flexion was 135 degrees and extension was 0 degrees. The examiner noted the CI was able to perform ROM easily, without crepitus noted, but with some discomfort. There was no ROM change after repetitive motion. Motor strength and sensory examination were normal.  Instability and meniscus testing were not addressed.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left knee condition 20%, coded 5257 (knee, other impairment), citing positive instability 2A Lachman and anterior draw tests status post two ACL reconstructive surgeries. The VA rated the left knee condition 10%, coded 5299-5259 (cartilage, semilunar, removal of, symptomatic), based on the C&P examination, citing analogous to symptomatic removal of the semilunar cartilage. The panel agreed that a 10% rating for left knee instability was supported under code 5257, for persistent instability as reported on the two orthopedic and MEB NARSUM examinations status post two ACL reconstructive surgeries. The panel agreed there was no evidence to support characterizing the disability due to instability as moderate for higher rating under 5257. At the orthopedic and MEB NARSUM examinations some laxity was noted with a firm endpoint (an intact ACL) with negative testing for functional instability. At the VA examination the CI reported he seldom used his knee brace. The PEB rated the knee condition at 20% under the 5257 instability code, but the panel noted meniscal injury was also accounted for in the adjudication. Members therefore concluded that consideration of dual coding of the knee was appropriate.

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). The persistence of pain after meniscal surgery warranted a 10% rating under the 5259 code (cartilage, semilunar, removal of symptomatic), or

alternatively there was satisfactory evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45), as reported on the MEB NARSUM and VA ROM examinations. There was no evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or fracture, nonunion or malunion of the femur or tibia causing a knee impairment (5255, 5262), proximate to separation, to support a higher rating under those codes. The panel’s rating recommendation of a dual rating of 10% for instability, coded 5257 and 10% for symptomatic meniscus following surgery, coded 5259 results in the same combined 20% rating recommendation for the knee condition as that of the PEB. Since there is no rating benefit to the CI, no change to the PEB adjudication 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 recommends a change in the PEB adjudication for the left knee condition.

BOARD FINDINGS. In the matter of the left knee injury 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.

	PD-2017-03577

AR20190010678, XXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXX

	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.

	PD-2017-03577