RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2022-00014
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Military Police, medically separated for “left knee instability following three ACL reconstruction surgeries” and “left knee limitation of motion,” rated 10% each, with a combined disability rating of 20%.   

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 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 – 20091006 	VARD – 20091005	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Instability	5257	10%	Left Knee Instability	5257	10%	20090522	
Left Knee Limitation of Motion	5260	10%	Left Knee…	5260	10%	20090522	
Recurrent Migraine Headaches	Not Unfitting	Recurrent Migraine…	8100	10%	20090811	
Traumatic Brain Injury (TBI), Concussion with Residual of Headaches	Not Unfitting	TBI, Concussion with Residual of Headaches				
Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD)	Not Unfitting	PTSD  	9411	30%	20090615	
Bilateral Tinnitus	Not Unfitting	Bilateral Tinnitus	6260	10%	20090626	
Asthma	Not Unfitting	Asthma	6602	30%	20090522	
Overactive Bladder	Not Unfitting	Overactive Bladder	7599-7519	0%	20090522	
Rhinosinusitis	Not Unfitting	Rhinosinusitis	6522	0%	20090522	
Thoracic Strain	Not Unfitting	Thoracic Strain	5242 	10%	20090522	
Degenerative Arthritis of Lumbar Spine	Not Unfitting	Degenerative Arthritis of Lumbar Spine				
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%  	

ANALYSIS SUMMARY:  

Left Knee Instability and Limitation of Motion.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in May 2007 during a vehicle accident while deployed to Iraq.  In August 2007, he underwent a homologous anterior cruciate ligament (ACL) graft but continued to have pain and instability.  After a follow-up diagnostic arthroscopy, the CI had a second ACL reconstruction with a cadaver allograft to stabilize the knee.  In June 2008, he underwent a third surgery with revision of the ACL allograft reconstruction, extraarticular reconstruction of IT band tenodesis, and removal of hardware.  

At the 22 May 2009 VA Compensation and Pension (C&P) examination, 7 months before separation, the CI reported constant localized pain that was burning, aching and sharp, and rated at 8/10 in intensity.  Physical examination showed left knee tenderness but no evidence of effusion, weakness, or guarding of movement.  Range of motion testing revealed flexion to 120 degrees (normal 140) with pain and extension to 0 degrees (normal).  After repetitive use, the left knee joint function was additionally limited by 4 degrees.  Anterior and posterior cruciate ligaments stability tests revealed slight instability, but medial and lateral collateral ligaments stability tests were within normal limits.  Medial and lateral meniscus tests were also normal.  

The 8 September 2009 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of pain, instability and swelling at the end of the day.  Physical findings revealed an antalgic gait, tenderness, and visible atrophy.  The examiner documented marked joint instability with femur rotation which then reduced spontaneously with a clunk accompanied by palpable and audible crepitus.  Lachman's testing for ACL integrity was negative, and there was no medial or lateral ligamentous laxity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee instability 10%, coded 5257 (knee, other impairment of: recurrent subluxation or lateral instability), citing instability following three ACL reconstruction surgeries.  The PEB also rated the left knee 10% for limitation of motion, coded 5260 (leg, limitation of flexion).   The VA assigned the same ratings and codes, citing slight lateral knee instability and objective medical findings of painful motion.  Panel members agreed, there was evidence of slight left knee lateral instability to support a 10% rating, but no higher, under diagnostic code 5257.   There was also sufficient evidence of pain limiting motion to warrant a 10% rating under code 5260.  The panel considered other VASRD knee and analogous codes, but all were less applicable and not advantageous for rating.  There was therefore no higher rating than the 20% adjudicated by the PEB.  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.  

Contended PEB Conditions:  The panel’s main charge was to assess the fairness of the PEB determinations that the following contend conditions were not unfitting.  

Migraine Headaches.  This condition was profiled and failed retention standards.  The commander noted the CI was incapacitated by migraines for at least an hour at a time at least once a week but did not define “incapacitating.”  There was no indication that the CI had to change his work environment, was sent home from work, or sought medical treatment during the one-hour period of incapacitation.  There were no documented performance issues related to the headaches.  His performance was favorably reviewed by his supervisors as well as his chain of command at the Warrior Transition Unit, where he demonstrated a strong work ethic and positive attitude.  The PEB noted that there were minimal entries in the CI’s health record regarding headaches treatment or any adverse impact on work, and that the mere presence of a physical condition did not constitute a disability nor an unfit determination.  Panel members agreed there was not a preponderance of evidence demonstrating the condition would have caused the CI to be unfit for duty.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the migraine headaches, so no additional disability rating is recommended.  

PTSD/MDD.  These mental health conditions were profiled S3.  The commander stated that the impact of these conditions to the CI’s his everyday life was “limited, other than trouble waking in the morning.”  The commander also noted no observations of decreased ability to perform tasks, behavioral concerns, mood symptoms, or any negative interactions with co-workers or supervisors that impacted duty performance.  The PEB documented that the STR contained “entries relating to depression in the face of marital difficulties” and that the CI’s performance had not declined because of the mental health conditions.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended PTSD and MDD, so no additional disability ratings are recommended.  

Traumatic Brain Injury, Bilateral Tinnitus, Asthma, Overactive Bladder, Rhinosinusitis, Thoracic Strain, and Degenerative Arthritis of Lumbar Spine.  None of these conditions were profiled or implicated in the commander’s statement, and none failed retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of these contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left knee conditions and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended migraine headaches and PTSD/MDD, the panel agrees it cannot recommend additional disability ratings for these conditions.  In the matter of the contended traumatic brain injury, bilateral tinnitus, asthma, overactive bladder, rhinosinusitis, thoracic strain, and degenerative arthritis of the lumbar spine, the panel recommends no change from the PEB determinations as not unfitting.  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:

Exhibit A.  DD Form 294, dated 20220117, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20220010855 

Dear XXXXXXXXXXXXX:

	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.