RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04989
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Power-Generator Equipment Repairer, medically separated for “chronic bilateral knee pain,” each rated 10%, with a combined disability rating of 20%.

CI CONTENTION:  “Finger had reconstructive surgery, torn meniscus in the 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’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 - 20090225	VARD - 20080819	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee 	5299-5257 	10%	Right Patellofemoral Degenerative Disease	5257	30%	20080703	
		10%	Left Patellofemoral Degenerative Disease	5257	10%	20080703	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent patella reduction surgery at the age of 15.  After recovery he was able to run 14 miles and play high impact sports, but in September 2006, following a ruck march, he complained of bilateral knee swelling and pain.  Since that time, he has had daily knee swelling that prevented bending.  A December 2006 examination revealed subluxed bilateral patella with poorly developed quadriceps.  X-rays demonstrated patellofemoral degenerative disease, right greater than left.  

The 5 February 2007 MEB NARSUM examination, 12 months prior to separation, noted complaints of intermittent bilateral knee pain.  Physical examination showed normally aligned bilateral knees in the frontal plane, but the CI stood with bilateral recurvatum (hyperextension backwards).  There was no bilateral knee effusion, instability or meniscus impingement, but there was mild patellofemoral crepitus (grinding) with extension noted more on the right knee than left.  Patellofemoral tracking was normal and the apprehension sign was negative.  Both patellae had above average mobility.  Repetitive right and left knee flexion was 138 degrees (normal 140) and extension 8 degrees (normal 0).  Painful motion was not addressed.

At a primary care clinic on 16 April 2007 the CI reported sustaining an injury to the right knee after falling 2 days earlier.  X-rays showed no fracture.  The CI had swelling and effusion of the right knee with tenderness of the prepatellar and medial collateral ligament areas and decreased ROM.  A right knee MRI in May 2007 showed a lateral patellar dislocation injury and an osteochondral defect along the posterior ridge of the patella, possibly with displaced bony fragments.  There was a partial tear of the medial patellar retinaculum (helps hold the patellar in place), anterior and superior fibers of the medial collateral ligament and moderate to large joint effusion.  

An orthopedic examination on 6 June 2007 revealed right knee effusion and increased lateral mobility of the patella and tenderness.  Clarke’s sign (to test for patellofemoral syndrome) and patellofemoral apprehension test were positive.  There was no ligamentous laxity or evidence of a meniscal tear.  Right knee ROM testing was normal, but pain was elicited with flexion at 90 degrees.  During the 25 June 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported bilateral knee pain and swelling.  Physical examination revealed right knee extension of -12 degrees (hyperextension) and left knee extension of -16 degrees (hyperextension); painful motion was not addressed.  A physical therapy ROM examination on 27 June 2007 revealed bilateral knee flexion of 135 degrees and extension of -5 degrees (hyperextension).  There was no limitation of motion due to pain.  The 6 August 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of bilateral knee pain with throbbing, stabbing and sharp-dull pressure, aggravated by prolonged sitting, standing, walking or running.  

At the 3 July 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported bilateral knee pain.  Physical examination of the right knee showed a hypermobile and tender patella with effusion and crepitus.  The knees were ligamentously stable.  Right knee flexion was 140 degrees and extension was -10 degrees (hyperextension).  Left knee was examination was negative except for a hypermobile patella.  Flexion was 140 degrees and extension was -20 degrees (hyperextension).  There was no pain on motion of either knee and no loss of ROM after repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee conditions 10% each, analogously coded 5299-5257 (knee, other impairment) citing minor functional loss caused by pain from repeated use or flare-ups.  The VA rated the left knee condition 10%, coded 5257, based on the C&P examination, citing recurrent slight subluxation or lateral instability.  The VA rated the right knee condition 30%, coded 5257, based on the C&P examination, citing recurrent severe subluxation or lateral instability. 

Left Knee.  There was no evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion that attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did demonstrate the presence of slight ligamentous instability or laxity (5257), based on the report of subluxed patellae in November 2006, which offers a 10% rating.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under that code.  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).  However, the CI did have recurvatum of the left and right knees with hyperextension between 5-8 degrees noted during examinations prior to separation and 20 degrees hyperextension at the VA C&P examination.  Therefore, code 5263 (genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated)) offers an alternative 10% rating option since the CI was unable to run and swelling was reported.  However, this offers no rating benefit to the CI.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating 10% for the left knee condition, coded 5257.  

Right Knee.  The panel noted the CI had a dislocation of his right kneecap and patellar reduction surgery prior to enlistment, which was service aggravated as noted above.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did demonstrate the presence of moderate ligamentous instability or laxity (5257) based on dislocation of the patella and hypermobility evidenced on examinations during and after separation, to support a rating of 20%.  Although there was a history of loose bodies confirmed by MRI findings, recurrent effusions and pain, there was no locking or evidence of dislocated semilunar cartilage (5258) to support a rating under that code.  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).  The CI also had right knee recurvatum and code 5263 offers a 10% rating option for the right knee; however, it provides no additional benefit to the CI.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating 20% for the right knee, coded 5257.

BOARD FINDINGS:  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5257 IAW VASRD §4.71a.  In the matter of the right knee condition, the panel recommends a disability rating of 20%, coded 5257 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Knee Pain	5257	10%	
Chronic Right Knee Pain	5257	20%	
COMBINED	30%	

XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure