RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200926 SEPARATION DATE: 20070216 BOARD DATE: 20130226 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (91W/Medical Specialist), medically separated for chronic right knee pain status post (s/p) arthroscopy for lateral meniscus tear. CI’s pain began during an AGR run and doing fireman’s carry in the field. CI had a magnetic resonance imaging (MRI) exam that showed a torn meniscus on the right knee in November 2006. The chronic right knee pain condition could not be adequately rehabilitated. The CI did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Adjustment disorder condition, identified in the rating chart below, was also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the right knee condition as unfitting, rated 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “I feel that my conditions were just as severe when I was medically discharged as they are now. If I am already rated at 70% through VA that leads me to believe my rating from the Army should be much higher. I originally filed for VA compensation with a few days after separating from Army. However they did not act on original filing. So I had to re-file using DAV help and it was eventually acknowledged that my original filing date was well within 12 months of my separation date. I have since appealed their original decision and submitted additional documentation & proof of severity of injuries & ailments and thus have been awarded 70% rating which I feel is a more accurate rating. Based on current claims.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The unfitting chronic right knee pain condition meets the criteria for Board purview and is addressed below. The additional condition of adjustment disorder was also forwarded on the DA Form 3947; however, it is not a ratable condition IAW DoDI 1332.38 Enclosure 5.1.3.9 and will not be discussed further. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20070206 VA (17 Mos. Post-Separation) – All Effective Date 20090526 Condition Code Rating Condition Code Rating Exam Chronic Right Knee Pain Status Post Arthroscopy for lateral Meniscus Tear 5099-5003 10% Right Meniscus Tear, Status Post Arthroscopy (claimed as right knee lateral meniscus) 5260 *10% 20090728 Adjustment Disorder Not a physical disability Adjustment Disorder with Depression 9434 *0% 20090729 .No Additional MEB/PEB Entries. Not Service-Connected x 1 Combined: 10% Combined: *10% * R. knee, 5260 with temporary 100% ratings in 2009 and 2010; 9434 increased to 70% effective 20111005 (combined 70%) ANALYSIS SUMMARY Chronic Right Knee Pain Condition. The narrative summary (NARSUM) notes the CI had arthroscopic knee surgery about 3 months prior to separation due to pain and instability of the right knee following an injury with meniscus tear. An MRI of the right knee was done prior to surgery and showed a right knee lateral meniscus tear. Service treatment records (STRs) show many medical treatment visits for bilateral knee pain diagnosed as patellofemoral pain syndrome (PFPS) prior to the diagnosis of the right lateral meniscal tear and multiple temporary profiles for one or both knees. The CI was made aware that the surgery was for the lateral meniscal pain and would not help the patellofemoral pain. The goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation are as summarized in the chart below. Right Knee ROM MEB ~2 Mo. Pre-Sep VA C&P ~17 Mo. Post-Sep Flexion (140° Normal) 135° 130° Extension (0° Normal) 0° 0° Comment: Surgery 3 Mo. Pre-Sep, & 6 & 22 Mo. Post-Sep Normal strength and sensation; no laxity; positive quad atrophy (see text) Slight limp; brace; painful motion; tenderness; normal strength; no instability (see text) §4.71a Rating 10%-20% (PEB 10%) 10%-20% (VA 10%) At the MEB exam it was noted that post-operatively (within a month) the CI continued to have knee pain that prevented him from taking any primary or alternate Army Physical Fitness Test (APFT). The MEB exam showed knee ROM noted in the table above. He had a positive grind with no apprehension, no patellar tilt or laxity. Motor and sensory were intact. There was no crepitus or swelling. There was a negative Lachman’s; “negative drawers;” negative McMurray’s; and no laxity with varus or valgus stressing. He did have quadriceps atrophy on the right and tenderness to palpation of the lateral collateral ligament. The narrative summary (NARSUM) stated the “MEB physical was 2 November 2006.” Surgery was 29 November 2006. The physical exam stated “The soldier is *ambulating with crutches at this time and *wearing a stabilizing brace on his right knee. He has obvious quad atrophy noted with girth on the right measuring 40.8 and on the left measuring 42.4. He has a positive grind with no apprehension, no patellar tilt or laxity” which was typed with the asterisked areas having hand-written “not” inserted over the typed text. The record documented that in addition to the knee surgery 3 months prior to separation, the CI underwent additional right knee arthroscopic surgery with partial lateral menisectomy and lateral knee cyst excision 6 months after separation. At the VA Compensation and Pension (C&P) exam performed about 17 months after separation, the CI reported weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability, tenderness, pain and dislocation of the right knee. He reported flare-ups, 10 times per where his knee “pops out of place and can’t move.” He rated the severity level 10. He reported difficulty with standing and walking; but his condition had not resulted in any incapacity. He reported that he might have to quit his job because he “can’t sit for long periods and no standing, brace required.” The VA exam showed three scars on the right knee that were not painful, disfiguring and did not restrict motion. There was no swelling, instability, locking pain, or crepitus of the right knee. ROM was as noted in the table above and was additionally limited by pain after repetitive use. The examiner listed pain and decreased motion as the residuals of the CI’s right knee lateral meniscus tear and the effect on his occupation was moderate due to pain; the effect on his daily activity was none. Records documented that the CI had continued “catching in the knee” and underwent additional right knee arthroscopic surgery 22 months post-separation with partial lateral menisectomy. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the right knee condition as 5099-5003 at 10% and cited the USAPDA Pain policy. The VA rated 5260 (limited leg flexion) at 10%. The Board noted that the MEB was accomplished within a month following knee surgery and the PEB noted and referenced obvious quadriceps muscle atrophy. The CI had additional symptoms from a knee cyst and meniscal tear within 6 months following separation. By the 17 month remote VA exam, the atrophy had resolved, however, meniscal symptoms persisted. Although the VA exam did not document objective meniscal signs, the CI underwent meniscal surgery repair within 5 months after that exam. Given the MEB-noted quadriceps atrophy, continued knee symptoms of meniscal pathology; and second meniscal repair within 6 months of separation, the Board considered the CI’s disability picture at the time of separation was closest to the disability picture portrayed by analogous coding as 5258 (Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) at 20%. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher of two evaluations), the Board recommends a disability rating of 20% for the right knee condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating the right knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic right knee pain condition, the Board unanimously recommends a disability rating of 20%, coded 5099-5258 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Right Knee Pain 5099-5258 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120619, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxx, AR20130006058 (PD201200926) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)