RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201190 SEPARATION DATE: 20021225 BOARD DATE: 20130306 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty 1LT (13A/Artillery), medically separated for diabetes mellitus (DM) requiring oral hypoglycemic and chronic pain, left knee. The CI reports having blurred vision, frequent urination and nocturia in January 2002. He was tested and diagnosed with diabetes in March 2002 and prescribed daily medication. Though his diabetes was controlled with medication the CI was unable to perform his Military Occupational Specialty (MOS) duties due to possible hypoglycemic reactions of the medications required to control his diabetes. Additionally, the CI reports having non-traumatic left knee pain first occurring in November 2001; after playing football during physical training. CI was diagnosed with a medial meniscus tear and received arthroscopic surgery in January 2002. The CI did not respond adequately to operative and rehabilitative treatment to meet the physical requirements of his MOS or satisfy physical fitness standards. He was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB). DM and left knee pain were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. There were no other conditions forwarded to the PEB. The PEB adjudicated the DM as unfitting rated 20% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD), while the chronic pain, left knee was rated 0%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 20% disability rating. CI CONTENTION: “Type II diabetes, renal insufficiency secondary to diabetes; left knee meniscus tear repair; degenerative arthritis lumbar spine; blurred vision secondary to diabetes.” 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 DM and left knee conditions requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The contended blurred vision and renal insufficiency secondary to diabetes are considered by the Board only with regard to rating the unfitting diabetes and are otherwise outside the scope of the Board. Any condition 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 20021016 VA (~2-3 Mos. Pre-Separation) – All Effective Date 20021226 Condition Code Rating Condition Code Rating Exam DM 7913 20% Renal Insufficiency Secondary to DM 7541 60%* 2021004 DM Type II 7913 20%* 20021004 Blurred Vision secondary to DM 6099 NSC* 20020902 Chronic Pain, Left Knee 5099-5003 0% Residuals of Left Knee Meniscus Tear Repair 5262 10%* 20021004 No Additional MEB/PEB Entries Degenerative Arthritis Left Spine 5010 10% 20021004 Combined: 20% Combined: 70% *No rating changes found in subsequent VARDs ANALYSIS SUMMARY: The Board acknowledges the CI’s contention that suggests ratings should have been conferred for other conditions documented at the time of separation. The Board wishes to clarify that it is subject to the same laws for disability entitlements as those under which the Disability Evaluation System (DES) operates. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. However the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service- connected conditions and to periodically reevaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. Diabetes Mellitus Condition. The CI was diagnosed with DM, Type II, in January 2002. He was treated with an oral hypoglycemic agent and referred to nutrition consult for diet modification. Although the CI's activities were restricted for diabetes control, there was no regulation of his activities and he was able to continue being active in his personal and professional life. The CI never experienced any ketoacidosis and was never hospitalized due to the diabetes. He had some blurred vision likely related to transient elevations in blood sugar; ophthalmological examinations on 29 March 2002, and 2 September 2002 showed he only required eyeglasses and that he had no eye complications of diabetes. Tests to evaluate kidney complications of his diabetes had revealed no microalbumin in the urine and blood kidney tests have been normal or at worst showing minimal effect on the kidneys. The CI was not treated with Insulin. At the MEB physical exam on 27 August 2002 (4 months prior to separation), the CI's diabetes was well controlled and he was being treated with oral medications. At the VA Compensation and Pension (C&P) evaluation on 4 October 2002 (2 months prior to separation), it was noted that the diabetes was well controlled and treated with oral hypoglycemic agent and diet and activity restriction. His hemoglobin A1C level was normal (indicating good diabetes control). His eye exam was normal. His urinalysis was normal. Blood tests related to kidney function showed values of BUN at 20 (normal range 9-21) and creatinine at 1.31 (normal range 0.7-1.4); these values were just at the upper limits of normal and at the most suggested only minimal adverse effect on the kidneys as a complication of the diabetes. Two ophthalmological examinations within one year of separation revealed no eye complications of diabetes. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the DM 20% coded 7913. The VA rated the DM Type II 20% coded 7913. Under the applicable code 7913 of the VASRD, the Board noted that the CI's DM was treated with diet and oral hypoglycemic agent (did not require Insulin), and was in good control. The Board adjudged that the CI’s activity restriction did not reach the VASRD code 7913 level of “regulation of activities.” The Board adjudged that the CI had no ocular complications due to diabetes and that there was little evidence to support any significant renal complications from diabetes. The Board concluded that the DM warrants a 20% rating under diagnosis code 7913 and the higher rating of 40% is not supportable since the CI was not treated with Insulin. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the DM condition. Chronic Pain, Left Knee Condition. The CI reported left knee pain first occurring in November 2001 after playing football during physical training (PT). He was diagnosed with a medial meniscus tear and received arthroscopic surgery in January 2002. At an orthopedics evaluation on 14 May 2002, the CI's range-of-motion (ROM) was flexion to 140 degrees and extension to 0 degrees; however this exam was not probative since the CI was still recovering from knee surgery. The CI received physical therapy; however he did not respond adequately to the operative and rehabilitative treatment and was referred for a Medical Evaluation Board (MEB). At the MEB physical exam on 27 August 2002 (4 months prior to separation), the CI had tenderness of near the left kneecap, no left knee instability, and a normal gait; his ROM was not measured. At the C&P exam on 4 October 2002 (2 months prior to separation), the CI stated he developed occasional swelling of the knee; however, he experienced pain in the knee with running or walking which usually lasted all day. His posture and gait were normal. ROM was 140 degrees flexion and 0 degrees extension (normal 0-140 degrees). He also had pain with motion of the left knee. The knee joint had no instability. X-ray of the left knee showed no abnormality. The Board directs attention to its rating recommendation based on the above evidence. The PEB applied the USAPDA pain policy in effect at the time and rated the left knee, chronic pain as 0% using diagnosis code 5099-5003. The VA rated the residuals of left knee meniscus tear repair 10% coded 5262. The Board considered the applicable codes for the left knee condition: 5257 knee instability, 5259 removal of semilunar cartilage, 5260 limitation of flexion, 5261 limitation of extension, and 5003 degenerative arthritis. Based on the ROM noted above, and the absence of any left knee instability, the Board concluded that the CI would be rated 0% under 5257, 5260, and 5261. With involvement of only one major joint and no limitation of motion, the CI would also rate 0% under code 5003. The Board then considered code 5259, removal of symptomatic cartilage. The Board concluded that in addition to the underlying left knee cartilage pathology requiring surgery under this code, application of VASRD §4.59 (Painful motion) and VASRD §4.40 (Functional loss of the left knee due to limitation of activities like running and walking) combined to support a rating of 10% coded analogously as 5099-5259. The Board notes that the PEB's 0% rating was supported by the USAPDA pain policy in effect at time of PEB's adjudication, however it was not consistent with VASRD §4.71a rules based on information provided by the MEB and C&P examinations. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board recommends a disability rating of 10% for the chronic pain, left 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 chronic pain, left knee was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the DM condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication. In the matter of the chronic pain, left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5259 IAW VASRD §4.40, §4,59, and§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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Diabetes Mellitus 7913 20% Chronic Pain, Left Knee 5099-5259 10% COMBINED 30% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120603, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxx, AR20130007833 (PD201201190) 1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay. 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: a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay. b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay. c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay. d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options. 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 xxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)