RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX 	CASE:  PD-2017-04538
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060824

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Network Switch Systems Operator/Maintainer, medically separated for “left knee pain status-post surgery for anterior synovitis” with a disability rating of 10%.   

CI CONTENTION:  “Review all conditions.” 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 - 20060626	VARD – 20070920	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain…	5099-5003	10%	Left Knee Strain with Insomnia	5099-5024	10%	20060630	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee pain began in January 2005 while running, when he stepped in a pothole and twisted his knee.  He was treated in the emergency room, with the patella (knee cap) moved back into proper alignment.  Left knee X-rays on 25 March 2005 were normal, but pain persisted, and he was given a profile and treated with a nonsteroidal anti-inflammatory drug and tramadol (opioid-like medication).  

At an orthopedic visit on 14 July 2005, the examiner assessed “left pes anserine bursitis and lateral joint pain,” and on 16 September 2005, the CI underwent arthroscopic anterior synovitis debridement.  Despite medication, physical therapy, and the use of crutches and a cane, he continue to have persistent pain 8 weeks after surgery, especially with walking.  Examination by an orthopedic surgeon revealed left quadriceps atrophy of 3.0 cm on the left, compared to the right, and left peripatellar tenderness; continued rehabilitation was recommended.  At a 28 November 2005 follow-up orthopedic appointment, left knee range of motion (ROM) was 0-135 degrees (normal 0-140), with no effusion, skin mottling, or joint line tenderness.  However, the CI had persistent left knee pain, and the examiner assessed “likely” retropatellar pain syndrome, although complex regional pain syndrome was considered.  Gabapentin (for nerve pain) was prescribed along with physical therapy.  
	 
An orthopedic evaluation on 10 February 2006, 5 months after surgery, documented mild Grade II patellar chondromalacia (fragmentation and fissuring within soft areas of articular cartilage) without any other internal derangement.  On examination, there was patellofemoral joint tenderness circumferentially, but no effusion or joint line tenderness.  The ROM was 0-125 degrees, and left thigh circumference was 44.5 cm compared to 47 cm on the right.  A temporary L3 profile was issued on 28 March 2006 with restrictions of no prolonged walking, running, marching, jumping, or standing in formations without periodic breaks, and no carrying more than 20 pounds.  

During the 24 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported “knee pain, gives out” and “knee brace used when needed.”  Physical examination revealed decreased left knee ROM and strength.  The MEB NARSUM examination the same day noted complaints of constant left knee pain, rated at 7/10, that was aggravated by walking, climbing stairs, and prolonged standing and sitting.  Physical examination showed an antalgic gait.  The CI used a cane for ambulation, but could walk without it.  There was no redness, warmth, swelling or laxity.  Left knee flexion was to 130 degrees (normal 140) and extension to 0 degrees (normal); lower extremity muscle strength was normal.  

At the 30 June 2006 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported left knee weakness, stiffness, giving way, lack of endurance, and fatigability.  He experienced constant pain, rated at 8/10, and used hydrocodone (narcotic and analgesic pain reliever) for relief.  Physical examination showed flexion to 120 degrees and extension to 0 degrees, with pain at the limits of motion; ROM was additionally limited by 20 degrees after repetitive use.  There was no laxity or evidence of a meniscal tear.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing application of the US Army Physical Disability Agency pain policy.  The VA also rated the left knee condition 10%, but analogously coded 5099-5024 (tenosynovitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  Members agreed 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) as adjudicated by the PEB. 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), or history of surgery to remove a meniscus (5259) to support a rating under those 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).  Therefore, there was no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 pain condition.   

BOARD FINDINGS:  In the matter of the 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:

[AR Number], XXXXXXXXXX

Dear XXXXXXXXXX:

	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.
 
	A copy of this decision has been provided to the counsel you listed on your application; [name and address].