RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04621
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Infantryman, medically separated for “chronic pain, right knee status post [s/p] two ACL [anterior cruciate ligament] operative repairs” with a disability rating of 10%.  

CI CONTENTION:  “The rating was not high enough with the amount of damage done to my 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’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 - 20061116	VARD - 20080411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Knee… 	5099-5003	10%	ACL Rupture, Right Knee, S/P Ligament Reconstruction	5257	20%	20080318	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI suffered a right knee twisting injury in 2002 during a road march, and underwent an ACL reconstruction with a patellar tendon autograft and meniscal repair in October 2004.  In February 2005, X-rays showed no evidence of any graft loosening or failure, but the lateral joint space was widened and there was evidence of an old medial collateral ligament (MCL) avulsion of the medial femoral condyle as well as a possible lateral Segond (avulsion) fracture of the proximal tibia.  In March 2005, the CI had an arthroscopic medial meniscal repair of a peripheral detachment and anteromedial and anterolateral rotary instability repairs.  

At a VA orthopedic consult on 12 July 2005, he reported continued instability and wearing a functional brace ever since the original injury, although he did return to work as a cabinet maker.  On examination, there was moderate lateral collateral ligament (LCL) laxity, but no ACL laxity, effusion, or positive signs of a meniscal tear (McMurray’s test).  Knee range of motion (ROM) was 10-100 degrees, with painful passive motion, but no loss of motion with repetition.  On 13 July 2005, X-rays demonstrated mild degenerative joint disease with joint space narrowing.
  
At the 27 July 2007 MEB physical therapy ROM evaluation, 6 months prior to separation, the CI reported constant right patellar pain, especially inferiorly, rated at 2-6/10.   The provider noted he had the same gait with and without a knee brace, which showed decreased stance time on the right lower extremity and “asymmetrical hip hike during swing through.”  Flexion was to 120 degrees and extension to -3 degrees; painful motion was not addressed.  During the 16 August 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months before separation, the CI reported bilateral knee pain and “arthritis in knee.”  Upon examination, he wore a hinged metal brace and walked with a pronounced limp.  Right knee X-rays the same day showed mild to moderate degenerative changes.  

The 13 September 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of right knee pain aggravated by prolonged standing and stairs, with swelling on some days.  He also experienced occasional giving way if he did not wear his brace. Physical examination showed well-healed scars and no swelling or effusion.  Flexion was to 110 degrees and extension -3 degrees, with ROM limited by pain.   Lachman’s, anterior drawer and varus/valgus tests revealed no instability and McMurray’s and patellar compress tests were negative. There was no medial or lateral joint line tenderness, and the patella tracked well in the patellofemoral groove.  An MRI two days later indicated the majority of the ACL graft fibers were intact, but there was a fluid signal within the graft.  The LCL and MCL appeared functionally intact, but there was a longitudinal split in the central root of the posterior horn of the medial malleolus.  

At the VA rehabilitation clinic appointment on 21 May 2007, 3 months after separation, the CI complained of right knee pain, especially after prolonged walking.  He also reported instability, and using an ACL knee brace (since 2006).  Physical examination showed pain-free right knee ROM within normal limits, but there was a positive varus tilt (indicating LCL laxity) and a slight positive anterior drawer test (to determine ACL integrity).  During the 23 August 2007 VA orthopedic visit, 6 months after separation, physical examination showed right knee flexion to approximately 120 degrees.  There was some mild tenderness over the medial and lateral joint lines but no signs of instability. He had a 1+ opening to varus stress with a positive end point.  

At the 18 March 2008 Compensation and Pension (C&P) examination, 13 months after separation, the CI reported continued daily right knee pain aggravated by prolonged standing or walking.  He could walk fairly well in a straight line, but any attempt to walk on uneven ground was painful and difficult.  Physical examination showed that that he transitioned from the chair and examination table with minimal difficulty, and had a normal gait and well-healed surgical scars.  There was 1-2+ laxity of the MCL , a 1-2+ positive Lachman’s test without a pivot shift, and a 1+ anterior drawer sign.  There was a negative McMurray’s test, no patella compression signs, and a minimal amount of joint effusion.  Right knee ROM was 0-120 degrees with no further loss of motion with repetition due to pain, weakness, fatigue or in-coordination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded analogously to 5003 (arthritis, degenerative), citing slight and constant pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the right knee condition 20%, coded 5257 (knee, other impairment of), citing continued moderate recurrent subluxation or lateral instability.  Panel members agreed there was no limitation of flexion or extension (5260, 5261) which supported a minimal rating, but there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) at the NARSUM examination.  While the CI had persistent pain after meniscal surgery that warranted a 10% rating under code 5259 (cartilage, semilunar, removal of symptomatic).  this provided no benefit to the CI.  There was also no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); or 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 wore a knee brace and had a surgical ACL reconstruction and stability repairs, no instability was noted proximate to separation, and thus code 5257 was not justified.  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 right knee condition. 

BOARD FINDINGS:  In the matter of the right knee condition 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:

AR20190007239, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.