RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05680
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “partial tear, right ACL (anterior cruciate ligament)” and “left knee pain following ACL reconstruction,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  In addition to the right and left knee conditions, the CI also requested review of other conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20080703	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Partial Tear, Right ACL	5257	10%	No VA Examination Proximate to Separation in Evidence	
Left Knee Pain 	5099-5003	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Partial Tear, Right ACL.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right knee condition began insidiously in March 2006 after repeatedly dismounting from a tactical vehicle.  During the 4 April 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported right knee pain.  Physical examination revealed mild crepitus and tenderness.  MRI of the right knee on 18 April 2008, revealed a small to moderate joint effusion.  The examiner opined there was probably a chronic tear of the ACL as well as an abnormal meniscus (either mucoid change or menisco-capsular injury).  

The 25 June 2008 MEB NARSUM examination, 2 months prior to separation, noted complaints of right knee pain.  Flare-ups occurred with extensive use or negotiating slopes, either stairs or an incline.  Prolonged standing increased pain and led to a lack of endurance.  Right knee range of motion (ROM) measurements performed by physical therapy (PT) on 7 April 2008 showed flexion of 120 degrees (normal 140) and extension of -10 degrees (hyperextension; normal 0).  Painful motion was noted.  A same-day orthopedic evaluation noted complaints of right knee pain and instability.  There was patellar crepitus with full knee ROM.  Anterior drawer was negative (no laxity); however, KT2000 measurement (anterior-posterior laxity) was 1 mm (normal 0) and stable.  

At the VA orthopedic clinic appointment on 29 January 2009, 5 months after separation, the CI reported right knee pain, giving-way, popping, intermittent swelling and wearing an ACL brace.  X-rays revealed bilateral lateral subluxation of the patella and narrowing of lateral space (degenerative changes).  An MRI report revealed a complete tear in the right knee ACL.  On examination the CI had an antalgic gait favoring the left knee and quadriceps muscle weakness, left greater than right.  He had a positive pivot shift bilaterally and no good end point on Lachman’s test (anterior-posterior laxity).  There was mild patellofemoral pain bilaterally and slight lateral side laxity symmetric bilaterally.  There was no patellar apprehension or effusion.  Right knee ROM showed flexion of 135 degrees and extension of -7 degrees.  Pain was noted with extreme flexion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5257 (knee, other impairment of), citing “rated IAW DODI 1332.39, para E2.A1.1.15.2.3 [slight knee instability].”  There was no VA Compensation and Pension examination proximate to separation in evidence.  The panel noted no evidence of moderate or severe subluxation or lateral instability to support a higher rating under the 5257 code (knee, other impairment).  There was no limitation of motion (5260, 5261), history of surgery to remove a meniscus (5259) or history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under these respective codes.  There was likewise no fracture, nonunion or malunion of the femur or tibia to support consideration under the codes for knee impairment related to long bone conditions (5255, 5262).  

However, it was noted that the PEB rated the right knee condition 10% for instability, while also referencing a degree of knee functional loss and ROM limitation (due to pain) that factored in the disability.  The CI also contended for pain and panel members therefore concluded that consideration of dual coding for instability and painful motion was appropriate.  The MEB PT examination provided evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45) for pain-limited flexion, coded 5299-5260 (leg, limitation of flexion).  Given the diagnostic imaging evidence of meniscal abnormality, an alternative 10% rating analogous to 5259 was considered; however, there was no benefit to the CI as meniscal rating includes painful motion and no additional rating was supported.  After due deliberation, and considering all the evidence, the panel recommends a disability rating of 10% for right knee instability coded 5257, and a disability rating of 10% for painful limitation of motion coded 5299-5260.  

Left Knee Pain.  According to the STR and MEB NARSUM, the CI underwent left knee surgery in January 2005 for a torn ACL.  An MRI of the left knee in August 2007 revealed postsurgical changes of the ACL repair, with the appearance of a tear of the anterior horn of the lateral meniscus with extension to the inferior meniscal surface.  Additional surgery was offered and reasonably declined.  During the MEB examination, 5 months prior to separation, the CI reported constant left knee pain.  Physical examination revealed marked crepitus in the left patella and pain to palpation and movement.  No instability was noted.  

The MEB NARSUM examination, 2 months prior to separation, noted complaints of left knee pain.  Flare-ups occurred with extensive use or negotiating slopes, either stairs or an incline.  Prolonged standing increased pain and led to a lack of endurance.  The CI indicated the left knee still “gives way” on him, causing a feeling of instability or incoordination.  Fatigue and weakness didn’t appear to be a problem separate from pain.  Left knee ROM measurements performed by PT on 7 April 2008 showed flexion of 110 degrees and hyperextension of -10 degrees.  Painful motion was noted.  KT2000 measurement was 3mm, but the left knee was stable.  

At the time of the VA orthopedic clinic appointment, 5 months after separation, the CI reported left knee pain, giving-way, popping, intermittent swelling, and wearing an ACL brace.  X-rays revealed bilateral lateral subluxation of the patella and narrowing of lateral space (degenerative changes).  On examination the CI had an antalgic gait favoring the left knee quadriceps muscle weakness, left greater than right, and mild hamstring weakness.  He had a positive pivot shift bilaterally and no good end point on Lachman’s test (anterior-posterior laxity).  There was pain but no click with Murray’s (meniscal testing).  There was mild patellofemoral pain bilaterally and slight lateral side laxity symmetric bilaterally.  There was no patellar apprehension and no effusion.  Left knee ROM showed flexion of 135 degrees and extension of -5 degrees with pain during extreme flexion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5003 (arthritis, degenerative), citing periarticular pathology with limitation of motion.  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).  There was no history or evidence 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 codes.  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).  

Given the diagnostic imaging evidence of meniscal abnormality, an alternative 10% rating analogous to 5259 was considered; however, there was no benefit to the CI as meniscal rating includes painful motion and no additional rating was supported.  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 left knee condition.  

BOARD FINDINGS:  In the matter of the right knee condition, the panel recommends it be dual coded with a disability rating of 10%, coded 5257; and a disability rating of 10% coded 5299-5260, both IAW VASRD §4.71a.  In the matter of the left 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.  

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	
Partial Tear, Right ACL  	5257	10%	
Painful Motion [Right Knee]	5299-5260	10%	
Left Knee Pain 	5099-5003	10%	
COMBINED	30%	

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a permanent 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 permanent 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.