Author: JOHN J. D'ORAZIO
Last saved by: WEATHERS, JANICE R SrA USAF AFRBA AFRBA/AFBCMR
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD1201963
BRANCH OF SERVICE:  Army	BOARD DATE:  20130905
SEPARATION DATE:  20071220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (42A/Human Resource Specialist) medically separated for a chronic right knee condition.  The CI sustained an injury to her right knee while running to a bunker while deployed in Iraq in 2004.  She underwent surgery in an attempt to correct her problem and subsequent to extensive physical therapy, the condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The right knee condition, characterized as “right knee pain, s/p surgical repair” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded “nontropical celiac sprue” as not meeting retention standards.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic right knee instability” as unfitting, rated 10% with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The reason I was sent to the MEB was not the reason l was discharged.  I was diagnosed with Celiac disease and the Army doctors did not know what to do with me so put me through the MEB.  The MEB came back with my knees, wrist, and anxiety as a reason for my separation.  The doctors did not do enough of evaluating me at the time and missed that l had TBI.  I feel that the Army should have rated me properly.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right knee condition is addressed below.  The CI’s contended celiac disease is also reviewed.  The contended (left) knee, wrist, anxiety and traumatic brain injury conditions were not considered by the MEB/PEB and are therefore not within the purview of the board.  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 Board for Correction of Military Records (BCMR).

The Board acknowledges the CI’s assertions that her treatment by the military medical community was not fair, accurate, or thorough in properly assessing her physical disability disposition.  It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations; redress in excess of the Board’s scope of recommendations (as noted above) must be addressed by the BCMR and/or the United States judiciary system.

RATING COMPARISON:

Service IPEB – Dated 20071009 | VA - (7 and 1 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic R Knee Instability | 5257 | 10% | S/P Arthroscopic R Knee Surgery with Synovectomy | 5099-5020 | 10% | 20071126
Nontropical Celiac Sprue | Not Unfitting | Nontropical Sprue (Celiac Disease) | 7399-7325 | 0% | 20070503
No other MEB/PEB Conditions |
Combined:  10% | Combined:  *40%
*Derived from VA Rating Decision (VARD) dated 20071221 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Knee Instability.  The CI was first seen for right knee pain on 29 January 2001 when she presented with a 4-day history of pain without trauma.  A bone scan was suggestive of bilateral stress fractures of the distal tibiae and calcanei as well as stress reactions of the bilateral tibiae.  She was treated conservatively with resolution.  On 26 March 2002, she twisted her left knee and was again managed conservatively.  The record is then silent until 8 March 2004 when she fell running to a bunker and hit both knees on concrete.  She was again seen in physical therapy on 18 November 2004 when she reported a 3-month history of knee pain, left greater than right, which was the same as had been present prior to her deployment.  She was noted to have tenderness to palpation (TTP) over the bilateral patellar articular surfaces and to have a positive patellar grind bilaterally.  The range-of-motion (ROM) and strength were normal.  She was diagnosed with bilateral retropatellar pain syndrome.  X-rays were normal and several Magnetic Resonance Imaging (MRI) exams were ordered.  An MRI of the right knee on 27 April 2005 showed a medial meniscal tear (MMT) of the posterior horn.  The MRI of left knee, performed the same day, also showed a complex MMT of the posterior horn.  The CI underwent a left knee arthroscopy with MMT debridement on 21 September 2005, and on 23 January 2006 a right knee arthroscopy with MMT debridement and partial synovectomy.  The left knee healed well, but she had persistent pain in the right knee.  The Board noted that the right knee surgery documentation is incomplete, but determined that this had no bearing on adjudication.  The commander’s assessment dated 3 July 2007 noted that she could perform her duties in Garrison, but that she was not qualified to deploy due to the requirement to maintain a gluten free diet.  The narrative summary (NARSUM) was dictated on 30 August 2007, 4 months prior to separation and over 18 months after the second (right knee) surgery.  It referenced an orthopedic exam accomplished on 15 August 2007 which is not in the record.  The left knee had minimal diffuse medial tenderness, but was otherwise normal.  The right knee showed no pain by motion, TTP of the peri-patellar retinaculum and pes anserine burse, and no effusion.  The remainder of the right knee examination was unremarkable.  The ROM was performed in physical therapy on 11 July 2007.  It was noted that the CI had normal active and passive ROM although she did not reach VA normal (140 degrees of flexion and 0 degrees extension) with 122 degrees of flexion on the right and 123 degrees on the left with one degree of extension bilaterally.  The Lachman test, which measures anterior cruciate ligament stability, was 1+ bilaterally.  The Board noted that the orthopedic examination cited above, was by a more experienced examiner, a month more proximate to separation, and did not record any instability.  At the VA Compensation and Pension examination performed a month prior to separation, the CI reported that with her current relative inactivity due to the permanent profile, she had pain only when she has been driving for a long time or her activity had increased.  The VA examiner noted “she feels she can't do any activity beyond the slowest of the things she likes to do.”  She had a five degree loss of flexion on repetition, but her examination was otherwise unremarkable.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Knee ROM
(Degrees)

PT ~ 17 Mo. Pre-Sep

MEB ~ 5 Mo. Pre-Sep

VA C&P ~ 1 Mo. Pre-Sep

Flexion (140 Normal) | FAROM | 122 (P=127.33) | *FROM
Extension (0 Normal) | FAROM | 1 (P=3.67) | *FROM

Comment

Gait nml.  mild edema/effusion noted R knee. 7/10 knee pain.  Six months post-op R knee

Lachmann 1+ 
Otherwise normal exam.  ROM noted as normal

No limp, No redness, swelling or tenderness, DeLuca positive 5 deg flexion loss on repetition,

§4.71a Rating | 10% | 0% | 10%
*Extracted from VARD 
The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the condition 5257 (knee, other impairment with subluxation or lateral instability) rated at 10%.  The VA coded analogously 5099-5020 (synovitis) rated at 10%.  The Board noted that the PEB coding 5257 did not align with the knee exam, which was reported as normal by the orthopedist without subluxation or lateral instability at the NARSUM physical.  The Board noted there was no compensable loss of motion or painful motion on the MEB exam, but a positive DeLuca with 5 degrees of loss of flexion on repetition a month prior to separation on the VA exam.  The Board considered the VA approach to coding and opined that the analogous code 5099-5259 for semilunar cartilage removal, symptomatic, was a better fit to the CI’s procedure and symptoms, rated at 10%.  The Board noted that 5099-5259 also encompassed the concept of positive DeLuca equivalent to painful motion and fit the VA exam.  However, neither of these codes or any other coding option provided a route to a higher disability rating than the 10% adjudicated by the PEB.  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 adjudication for the right knee pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that nontropical celiac sprue was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI was issued a permanent P3 profile on 4 June 2007 for nontropical celiac sprue; this was the initial condition referred to an MEB.  The Board noted that the CI had been treated for abdominal pain since 2003 and that this might have represented symptoms of nontropical celiac sprue.  However, she was not diagnosed until she was evaluated for abnormal liver function tests which had been obtained as part of a routine examination for weight gain.  The clinician documented that the CI had a strong positive history and markedly positive serologic markers, but that she remained asymptomatic on a normal (that is, not a gluten free) diet.  Specifically, it was noted that she had no diarrhea, weight loss, anemia, or abdominal pain and that she had one bowel movement a day, well within the normal range.  The nontropical celiac sprue was the only condition implicated in the commander’s statement and was judged to fail retention standards due to the fact that she was restricted from deployment due to gluten free meals not being available during deployment.  However, this would not preclude continued service in Garrison where she could maintain a gluten free diet.  The nontropical celiac sprue condition was reviewed by the action officer and considered by the Board.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of nontropical celiac sprue condition did not favor its recommendation as an additionally unfitting condition for disability rating.  While the condition was noted to interfere with possible deployment, the CI was able to function well in Garrison and retention was a reasonable determination by the PEB.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended nontropical celiac sprue condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 Knee Instability Condition | 5257 | 10%
Nontropical Sprue | Not unfitting | ---
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20121211, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB / XXXXXXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, AR20130021946 (PD201201963)

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						     XXXXXXXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

PD1201963