RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201476 SEPARATION DATE: 20021202 BOARD DATE: 20130320 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (77F/Petroleum Supply Specialist), medically separated for chronic right anterior knee pain. The CI has a long history of right knee pain that began when she experienced a right knee patellar dislocation during a run in her Advanced Individual Training in 1990. She underwent long-term conservative treatment to include physical therapy (PT). Her Military Occupational Specialty (MOS) was also reclassified. Despite orthopedics evaluations, an arthroscopy and debridement of a medial plica, occupational therapy (OT), physical therapy (PT), crutches and a knee brace, the CI failed to meet the physical requirements of her MOS or meet physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded right anterior knee pain to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. The MEB also forwarded non-allergic rhinitis, history of dyspnea, deconditioning and obesity, myopia corrected to 20/20 vision, bilateral pes planus, and migraine headache conditions to the PEB as medically acceptable. The PEB adjudicated the chronic right anterior knee pain, rated as slight condition as unfitting, rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting and not rated. The CI made no appeals and she was medically separated with a 10% disability rating. CI CONTENTION: “Continued right knee pain.” 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 rated condition chronic right anterior knee pain, as requested for consideration, is the only condition that meets the criteria prescribed in DoDI 6040.44 for Board purview; and, is addressed below. 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 PEB – Dated 20020917 VA (3 Mos. Post-Separation) – All Effective Date 20021203 Condition Code Rating Condition Code Rating Exam Chronic Right Anterior Knee Pain 5099- 5003 10% Status Post Plica, Osteoarthropathy of Right Knee 5010 10% 20030225 Non-allergic Rhinitis Not Unfitting Rhinitis 6522 0% 20030225 History of Dyspnea Not Unfitting Asthma 6602 30% 20030225 Bilateral Pes Planus Not Unfitting Bilateral Pes Planus 5276 0% 20030225 De-conditioning and Obesity Not Unfitting NO VA ENTRY Myopia, Corrected to 20/20 Vision Not Unfitting NO VA ENTRY .No Additional MEB/PEB Entries. Status Post Partial Hysterectomy 7618 30% 20030225 Tinnitus 6260 10% 20030225 Migraine Headaches 8100 10% 20030225 Not Service-Connected x 2 Combined: 10% Combined: 60% ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. Chronic Right Anterior Knee Condition. There were two 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) NARSUM ~3.5 Mo. Pre-Sep VA C&P ~2.87 Mo. Post-Sep Flexion (140 Normal) 130 140 Extension (0 Normal) 0 0 Comment stable varus/valgus; no effusion; stable anterior drawer; 1A Lachman’s (1-5 mm laxity); negative McMurray’s and grind test; “constant knee pain” No limitation of motion; McMurray test, drawer test normal; gait normal §4.71a Rating 10% 10% The CI had a well-documented history of right knee complaints in the service treatment record (STR) from March 1990 through to June 2002. The CI was seen by orthopedics for the constant right knee pain with running in September 1993. X-rays of the right knee in 1993, 2000, and 2001 were all negative along with magnetic resonance imaging (MRI) performed in September 2001. The CI continued to be followed by orthopedics and was given an intra-articular steroid injection in July 2001. The CI was given a sick slip for use of a knee brace and then was reevaluated by orthopedics for an arthroscopy. She underwent a right knee diagnostic arthroscopy with a medial plica excision in January 2002. The commander’s statement documented that the CI’s physical ability to perform her MOS duties had deteriorated and that she required access to an elevator because she was unable to walk up and down stairs or lift normal loads or weights. The MEB narrative summary (NARSUM) examination 3 months prior to separation indicated right knee pain that was moderate and frequent. Her pain was exacerbated by squatting–type activities and her right knee gave out three times while walking down stairs. The examiner opined that the CI was not expected to improve. The physical exam findings are in the chart above. The CI was issued an L3 profile with restrictions of no running, no jumping no road marching, and no lifting greater than twenty pounds. The VA Compensation and Pension (C&P) examination approximately 2 months after separation indicated that a recent MRI demonstrated right knee degenerative joint disease (DJD) and a right knee X-ray revealed mild osteoarthropathy of the knee joint. The examiner further noted that the CI continued to have pain, stiffness, and discomfort during running, kneeling, or prolonged standing and that she had lost approximately 3 weeks of work because of this pain. The physical exam findings are in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the chronic right anterior knee pain as analogous to 5003 Arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 10% with application of the USAPDA pain policy. The VA coded the right knee condition 5010 Arthritis, due to trauma, substantiated by X-ray findings. The C&P examination noted that mild osteoarthropathy of the knee joint on X-ray and right knee DJD on MRI. Neither exam indicated ROM limited to a compensable level for code 5260 (leg, limitation of flexion) or 5261 (leg, limitation of extension). The PEB applied the USAPDA pain policy in its determination of the 10% rating. However, use of this policy did not materially affect the rating in this case and a 10% rating is obtained when utilizing the VASRD alone for any of the ratable exams proximate to separation. VASRD §4.71a specifies for 5003 that “satisfactory evidence of painful motion” constitutes limitation of motion and specifies application of a 10% rating “for each such major joint or group of minor joints affected by limitation of motion” and VASRD §4.59 (Painful motion) provides an alternate justification for a 10% rating. The right knee condition could not be reasonably rated higher than 10% using any exam proximate to separation or any alternate rating schema. 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 chronic right anterior knee pain 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 right anterior knee pain 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 anterior knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Chronic Right Anterior Knee Pain 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120602, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxx AR20130007470 (PD201201476) 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 and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)