RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX 	CASE:  PD-2017-04370
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for “degenerative arthritis of the bilateral knees,” with each knee rated at 10%, and a combined disability rating of 20%.   

CI CONTENTION:  “Anxiety Disorder previously unrated was diagnosed as PTSD through the VA.  Left knee 10 A/C was not awarded for left knee…”  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 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 - 20081009	VARD - 20090211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis, Right Knee	5003	10%	Degenerative Joint Disease, Right Knee	5010	0%	STR	
Degenerative Arthritis, Left Knee 	5003	10%	Left Knee Condition, Postoperative	5260	NSC	STR	
Anxiety Disorder	Not Unfitting	Anxiety Disorder	9411	NSC	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Bilateral Knees.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was riding as a passenger in a tactical military vehicle in June 2005 when an IED exploded nearby causing him to jam both knees against a bar running across the back of the seat.  He was able to get out of the vehicle and “walk it off,” however, the next morning he had significant swelling and pain in both knees.  He was treated with a nonsteroidal anti-inflammatory drug (Motrin) and able to complete his deployment despite intermittent knee locking, popping, swelling and pain.  He was issued a profile for no running, and upon redeployment, he underwent physical therapy (PT) and injections.  

In August 2007, he had a left knee arthroscopic posterior horn medial meniscus debridement and developed locking and grinding post-operatively.  The right knee subsequently became symptomatic in approximately January 2008, with anterior pain, catching, locking, and popping; X-rays in April 2008 showed mild narrowing of the medial compartment of the right knee joint space and a soft tissue over the medial femoral condyle suggestive of a hematoma or tendon injury.  Left knee X-rays showed mild narrowing of the medial compartment of the knee joint space with a calcified loose body or accessory ossicle in the posterior aspect.  Bilateral knee MRIs on 25 April 2008 showed no tears on the left and an otherwise normal knee, while the right knee demonstrated a joint effusion and possible peritendinitis or an arthritic process. Additionally, there was possible thinning of cartilage along the posteromedial tibial plateau.  

The 17 July 2008 MEB NARSUM examination, 5 months prior to separation, noted CI complaints of bilateral knee pain, left greater than right, and the inability to run, jump and ruck march, carry field gear, or perform several of soldiering tasks.  Physical examination showed left knee tenderness at the anterior and posterior medial joint line, proximal medial tibial plateau, proximal lateral patellar ligament, and lateral collateral ligament.  There was no ligamentous laxity or swelling, but there was increased pain with varus stress along the lateral collateral ligament and a positive grind.  The right knee showed tenderness along the lateral proximal and medial proximal tibial plateau and patellar ligament.  There was a positive patellar grind and increased pain with ligamentous stress, but no swelling or ligamentous laxity.  Left knee flexion was to 105 degrees (normal 140), with pain, and extension to 0 degrees (normal).  Right knee flexion was to 110 degrees and extension to 0 degrees, with increased pain during repetition.  There was no VA examination in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 20% (10% for each knee), coded 5003 (arthritis, degenerative), citing limited ROM. The VA rated the right knee condition 0% coded 5010 (arthritis, due to trauma) citing no painful motion, and did not service connect the left knee, based on the STR examination, citing no permanent disability.  Panel members agreed that while there was no compensable limitation of flexion or extension (5260 or 5261), there was evidence of painful motion (increased pain with varus stress on the left and increased ligamentous stress on the right) with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was also no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), and while code 5259 (cartilage, semilunar, removal of, symptomatic) was applicable in this case, the maximum 10% rating under this code provided no benefit to the CI.  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).  Therefore, there was no applicable VASRD §4.71a rating higher than a 10% for either knee as adjudicated by the PEB.  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 bilateral knee condition.  

Contended PEB Condition:  Anxiety Disorder.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was profiled S1, but was not implicated in the commander’s statement, and did not fail retention standards.  The CI served as a combat medic and was exposed to deaths.  He was first seen in the behavioral health clinic (BHC) in May 2007 and was diagnosed with a personality disorder and subsequently with an adjustment disorder with anxiety.  When he was due to deploy again, he took a dagger and inflicted a wound to his knee.  A psychiatric evaluation cleared him of any administrative action deemed appropriate by his command and he was sent to a rear detachment.  At a BHC visit on 10 April 2008, it was determined he did not appear to meet criteria for posttraumatic stress disorder (PTSD), but had some trouble adjusting to life since his return from the theater.  Neuropsychological testing to rule out a traumatic brain injury was performed in May and June 2008.  Results revealed general cognitive functioning between low average and very superior levels. Personality testing was consistent with mild depression and social introversion.  The Axis I diagnoses were “adjustment disorder with depressed mood, rule out PTSD, and post-concussion syndrome, largely resolved.”  A MEB NARSUM addendum dated 28 August 2008 noted that a mental status evaluation revealed an affable man who was appropriate during the evaluation. There was no evidence of an overt psychosis, formal thought disorder, impaired reality testing, or disorder of perception or cognition.  Intelligence was estimated as normal, and speech was without pressure in a relevant, coherent, and logical manner.  Mood was euthymic and affect was consonant to mood and thoughts expressed. There was no suicidal or homicidal ideation, intent, or plan. The Axis I diagnosis was anxiety disorder, not otherwise specified, and the examiner determined the CI met retention standards.   There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder, the panel recommends no change from the PEB determination as not unfitting.  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:

 

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Dear XXXXXXXXXXXXXXXX

	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.