RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2018-00327
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20040820

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Asphalt Equipment Operator, medically separated for “osteoarthritis, left knee, status post anterior cruciate ligament [ACL] reconstruction with osteopenia by x-ray ” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made. 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 - 20040512	VARD - 20041013	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Osteoarthritis, Left Knee…	5003	10%	Status Post Anterior Cruciate Ligament Reconstruction with Degenerative Changes	5010-5260	20%	20040923	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Left Knee Osteoarthritis. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left knee condition began in June 2001 during a unit run while deployed, and he underwent an ACL reconstruction in February 2002 (he had a left knee medial arthrotomy about 27 years prior to this). On 26 August 2003, an orthopedic evaluation noted significant left quadriceps atrophy. The CI subsequently had two courses of Synvisc injections and was referred

for a total knee replacement after pain management treatment options were exhausted. At an orthopedic appointment on 5 December 2003, he reported moderate and intermittent pain, but denied giving away or buckling. He was able to walk unlimited distances without any support, but exhibited with a subtle limp. The provider noted moderate effusion and tenderness. Range of motion (ROM) measurements revealed flexion of 125 degrees (normal 140) and extension of
-5 (normal 0). The CI wanted to delay a knee replacement, and on 18 December 2003, he had his third Hyalgan injection and reported the pain was improved from before the injections.

During the 5 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported left knee pain, and the examiner documented moderate left knee edema and effusion with a well-healed anterior knee scar. There was decreased ROM with pain at the extreme of flexion, but Lachman and Drawer tests were negative. The CI had a “labored” antalgic gait and decreased left lower extremity strength. The MEB NARSUM examination, the same day, noted complaints of left knee pain and difficulty with prolonged walking as well as doing activities of daily living such as yard work. The pain was constant while awake, but he denied any sleep disturbances. Physical examination showed well- healed surgical incisions and visible atrophy with a 1+ Lachman with definite endpoint and no effusion. There was 1+ anterior drawer in neutral and internal rotation, but none during external rotation. Left knee ROM showed flexion of 135 degrees and extension of 10 degrees. The CI was ambulatory with a cane, and when full weight-bearing, he displayed a marked limp.

At an orthopedic follow-up on 17 February 2004, the CI reported improvement in his pain, and the provider noted “near full extension and 125 degrees of flexion.” At the 30 April 2004 orthopedic visit, he reported the injections only provided relief for about 3 months. Another set of injections were elected and the examiner stated the knee ROM was “well maintained.” On 24 June 2004, the orthopedist referenced X-rays demonstrating substantial arthritic change posteriorly of the left knee and more mild changes about the patellofemoral joint. A follow-up examination on 19 July 2004 noted the CI walked with an antalgic gait with no assistive devices, and had a small amount of knee swelling.  Measured ROM was from -5 to 125 degrees.

At the 23 September 2004 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported left knee pain with swelling and decreased ROM. He used a cane to ambulate and took over-the-counter Motrin and Celebrex to control the pain. Physical examination showed left knee ROM, following repetitive movement, of flexion to 60 degrees and extension to 10 degrees. Anterior and posterior drawer signs were negative with no medial lateral instability, but there was crepitus on ROM, extreme tenderness in the joint line space and a large effusion. The examiner noted the CI walked with an exaggerated limp because he was unable to fully bear weight on his left side.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the knee condition 10%, analogously coded 5003 (degenerative arthritis (hypertrophic or osteoarthritis)). The VA rated the knee condition 20%, analogously coded 5010-5260 (limitation of flexion of leg) based on the C&P examination, citing 10% for objective evidence of limited motion, crepitus on ROM, and joint line tenderness. An additional 10% was given for functional loss as evidenced by an exaggerated limp, inability to fully bear weight on the left side, the need for a walking cane, large joint effusion and advanced degenerative changes with scheduling of a total knee replacement. Panel members agreed there no limitation of flexion or extension (5260 or 5261) for a compensable rating, 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 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). 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 of the evidence and mindful of VASRD

§4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the knee condition.

BOARD FINDINGS: In the matter of the left knee condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication. The single voter for dissent recommends modification to 20% and did not elect to submit a minority opinion. 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.

PD-2018-00327

AR20190012264, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX

	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.

PD-2018-00327