RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201355 SEPARATION DATE: 20060818 BOARD DATE: 20130312 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (31B20/Military Police), medically separated for right knee pain. The right knee condition could not be adequately rehabilitated 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). The MEB forwarded “chronic knee pain with intermittent locking, tri-compartment degenerative joint disease, right knee condition” and no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the right knee pain condition as unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “I suffer from constant pain in my knee and have been told I will need a knee replacement but VA won't replace it until I am at least 55….I had 3 orthoscopic knee surgeries while on Active Duty and have since had another orthoscopic surgery done at the VA hospital to clean up the cartilage and bone and remove broken pieces of bone.” The CI also contends for service disability compensation for his ankles, hips, shoulder, neck, eye surgery, PTSD, blood clots, sleep apnea, nose, and hearing loss. 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 the unfitting right knee condition will be reviewed. The other requested conditions (right ankle pain, hip pain, blood clots, PTSD, sleep apnea, right eye cataract surgery, shoulder pain, discs in the neck, nose bleeds, and hearing problems) are not within the Board’s purview. 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 20060523 VA (~5 Mos. Post-Separation) – All Effective Date 20060819 Condition Code Rating Condition Code Rating Exam Right Knee Pain 5257 10% DJD, Right Knee, Post Operative 5010-5260 10% 20070111 .No Additional MEB/PEB Entries. PTSD 9411 30% 20070111 Degenerative Changes, Lumbar Spine 5242 10% 20070111 0% X 1 / Not Service-Connected x 6 Combined: 10% Combined: 40%* Based on VARD proximate to separation 20070214. Additional condition (ankle sprain added @10%) by VARD 20100223 effective 20060819. ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB. However the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. Right Knee Pain Condition. There were three goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Right Knee ROM (Degrees) PT ~5 Mos. Pre-Sep (20060314) MEB ~5 Mos. Pre-Sep (20060329) VA C&P ~5 Mos. Post-Sep (20070111) Flexion (140 Normal) 121 90-95 76 Extension (0 Normal) 7 15 8 Comment Flexion limited by pain Fell on knee morning of exam 15 degrees loss of extension 1+ Lachman (unchanged from entrance examination) Slight antalgic gait. Pain at end point of flexion 8 degrees loss of extension No instability Gait normal. §4.71a Rating 10% 20% 10% The MEB narrative summary (NARSUM) notes that the CI underwent an anterior cruciate ligament (ACL) reconstruction on his right knee in 1988, 4 years prior to entry into the military. At the time of enlistment medical examination, an orthopedic evaluation 17 June 1992 concluded the left knee ACL was deficient showing mild instability on examination with a 1+ Lachman, and positive pivot shift. The CI received medical clearance for entry into military service and entered active duty in September 1992. He reinjured the right knee in 1994 playing sports and underwent arthroscopic surgery in February 1995 and October 1996. Recurrent knee symptoms led to another arthroscopic surgery in February 2000 with findings of degenerative changes (chondromalacia) involving the medial and lateral femoral condyles, retropatellar surface, and the medial tibial plateau. A radial tear of the lateral meniscus was noted and was debrided. He did well post-operatively and was able to continue in his job. His MOS was changed to 31B (MP). The CI did well until a deployment to Iraq (deployed March 2004 to March 2005) when he underwent multiple episodes of intermittent locking beginning in November 2004 which inhibited his function as an active duty soldier. He returned with his unit from deployment and was subsequently evaluated by orthopedics. A torn meniscus was suspected. Magnetic resonance imaging (MRI) scan on 9 August 2005 showed degenerative changes but no meniscus tear. There was no clear visualization of the ACL and a tear could not be excluded. Follow up in physical therapy 24 August 2005 noted the history of right knee locking. On examination there was no instability, extension was normal, and flexion 110 degrees. At the time of a 20 October 2005 clinic examination, ROM was “full”, with patellar crepitus. There was no instability (negative Lachman, anterior drawer), and the McMurray test was negative for meniscus signs. The gait was normal and no tenderness was observed on ambulation. An MRI scan performed on 2 March 2006, showed degenerative changes with intact posterior cruciate ligament and collateral ligaments. The ACL could not be “demarcated” and the radiologist suspected a rupture of the previous repair. There was a “suspicion of a subtle tear” of the lateral meniscus, but no full tears or dislocated meniscus was noted. Physical therapy MEB ROM examination of the right knee on 14 March 2006 is recorded in the chart. At the MEB NARSUM examination 28 February 2006, the CI reported difficulty with prolonged standing, difficulty mounting and dismounting military tactical vehicles secondary to pain at the right knee. The pain was present approximately 10% of the time and depended upon activities. He was able to perform the aerobic portion of the fitness test with a walk or cycle and had accomplished this successfully for several years. On examination there was a slight antalgic gait secondary to a recent fall upon the right knee and apparent locking phenomena at the time of the examination. The right knee showed some slight swelling, and there was limitation of motion as recorded in the chart. There was a positive apprehension test and positive patellar grinding. There was a positive Lachman’s sign. The NARSUM does not specify the Lachman grade but the DA Form 199 cites the Lachman as 1+. There were well- healed scars from his prior knee surgeries. There was slight atrophy of the right quadriceps but muscle strength was normal (tested at 5/5). X-rays showed degenerative changes in the three compartments of the right knee. At the 11 January 2007 VA Compensation and Pension (C&P) examination, performed 5 months after separation, the CI reported he was employed full time as a correctional officer. He was able to perform his activities of daily living without difficulty. His right knee was associated with stiffness, swelling, instability, giving away, locking, and weakness. He had flares of symptoms 2-3 times a week that lasted about 3 hours. ROM is documented in the chart. There were complaints of pain with extremes of ROM testing. There was no evidence of meniscus tear, joint laxity, crepitus, and no neurological deficits. Gait was normal. X-ray impression was severe osteoarthritic changes. The Board directs attention to its rating recommendation based on the above evidence. The limitation of motion in flexion and extension from the physical therapy and C&P examinations did not attain a minimum compensable level, supported by the normal gait at the time of the C&P examination. The limitation of extension at the time of the MEB NARSUM examination was related to a fall the morning of the examination and was not reflective of the overall limitation of motion documented in the treatment records. The Board noted the PEB rated the knee condition using the code for knee instability (5257). The Board noted the MRI findings showing evidence of a deficient ACL and MEB NARSUM examination with a positive Lachman test graded 1+. However the pre-enlistment orthopedic examination also documented a 1+ Lachman test consistent with a deficient ACL indicating the existing prior to service mild instability had not worsened during service. There were no symptoms of instability recorded in the MEB examination. In addition, the C&P examiner (January 2007) did not find instability at the time of that examination. The Board also noted a C&P examination form May 2009 which did not find instability. Therefore the Board did not conclude rating under the 5257 code selected by the PEB was appropriate. There were intermittent symptoms of locking however MRI scanning did not show a dislocated meniscus to warrant rating under the respective code. The symptoms were consistent with the extensive post traumatic degenerative arthritis of the knee. The Board noted the presence of degenerative arthritis and functional limitations and agreed a 10% rating (§4.40) was supported by the evidence. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB rating adjudication for the right knee condition but concluded the rating was best coded as 5010-5003. 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. In the matter of the right knee pain/degenerative joint disease condition, the Board unanimously recommends a disability rating of 10%, coded 5010-5003 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 Right Knee Pain / Degenerative Joint Disease 5010-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120722, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxx, AR20130006288 (PD201201355) 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 description without modification of the combined rating or 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 xxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)