RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-00776
BRANCH OF SERVICE:  Army	BOARD DATE:  20150130
SEPARATION DATE:  20070819

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (15J/OH-58 Systems Repairer) medically separated for a right knee condition, which could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “chronic right knee pain/patellar chondromalacia,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501 (failing retention standards).  Three other conditions were forwarded as meeting retention standards:  left knee pain, right ankle pain/instability, and posttraumatic stress disorder (PTSD), in remission.  The Informal PEB adjudicated the right knee condition as unfitting, rated 0%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

IPEB – Dated 20070705	VA - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain ... Strain Injury, R Knee	5099-5003	0%	Chondromalacia, Right Knee	5014	10%	STR	
PTSD (in remission)	Not Unfitting	PTSD with Depression	9434-9411	NSC	STR	
Other x 2 (Not in Scope)	Other x 8 	
RATING:  0%	RATING:  10%	
Derived from VA Rating Decision (VARD) dated 20080229 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Knee Condition.  The STR confirms the onset of right knee pain after a fall down stairs in June 2004.  Magnetic resonance imaging (MRI) in November 2004 was suggestive of a meniscal tear, but there are no follow-up entries from that period.  The narrative summary (NARSUM) states that the CI deferred further intervention to deploy with his unit to Iraq (May 2005–February 2006).  Although suffering no further injury, the CI continued to experience knee pain upon re-deployment; and, an MRI in April 2006 was diagnostic for a meniscal tear (medial, posterior horn).  The CI underwent arthroscopic surgical debridement of the meniscus in August 2006.  There are numerous post-operative STR entries leading up to separation; and, abundant documentation that gait was normal, range-of-motion (ROM) was normal, post-operative effusion was resolved, and that there was no instability.  The CI continued to complain of pain, although there is documentation that he was remiss in physical therapy (PT) and activity restrictions because of various duty and personal conflicts.  Some PT notes documented signs of cartilage impingement (positive McMurray’s), but none recorded an associated complaint of locking.  The final orthopedic evaluation is from May 2007 (3 months prior to separation), and the examiner commented that “he does not have any mechanical symptoms or instability.”  It documented a normal gait, no effusion, stability in all planes, and “full ROM that is painful at extreme flexion.”

The NARSUM conducted on 13 June 2007 (2 months prior to separation) documented constant pain rated 4/10 on average, exacerbated by “any increased activity, especially prolonged standing or walking up or down stairs.”  The examiner further stated, “He denies any significant swelling of the knee, but states that it does lock up at least once or twice per day, with frequent popping.”  Physical findings for the knee were not documented in the NARSUM, but measured ROM was flexion 128 degrees (normal 140 degrees; minimum compensable 45 degrees) “limited by pain” and extension 0 degrees (normal).  The CI did not attend a scheduled post-separation VA rating examination, and there is no probative post-separation VA or other clinical evidence.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating analogous to code 5003 (degenerative arthritis) cited the normal ROM, but did not account for painful motion, which was adequately documented in the NARSUM and STR.  The VA’s 10% rating under code 5014 (osteomalacia, defaulting to 5003 criteria) specifically cited painful motion.  Notwithstanding application of VASRD §4.59 (painful motion) to achieve the minimum compensable rating of 10%, the Board notes that code 5259 (cartilage, semilunar, removal of, symptomatic) is clinically appropriate to this case and confers a 10% rating without regard to ROM or other criteria.  The Board considered application of code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint), which confers a 20% rating.  Although the NARSUM complaint of frequent locking and PT findings (positive McMurray’s) raise the possibility of loose cartilage, members agreed that this coding route was not adequately supported.  The final orthopedic exam specified that mechanical locking was not present, and the criterion of frequent effusions (a requisite for 5258) was refuted by multiple specific entries in the STR.  With the absence of instability, there is no other route to a rating higher than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the right knee condition; proposing code 5259 for its clinical specificity.

Contended PTSD.  The NARSUM and a psychiatric addendum document a diagnosis of PTSD in 2004 related to the CI’s first deployment to Iraq (March 2003-March 2004), although there are no associated MH records in the available STR.  The Post-Deployment Health Assessment from the 2005–2006 Iraq deployment recorded some psychiatric symptoms; but, did not relate typical PTSD symptoms or significant stressors.  Specifically the CI denied an interest in MH evaluation or counselling.  He was not prescribed any psychoactive medications or psychiatrically profiled.  At the time of the psychiatric addendum in June 2007, 2 months prior to separation, his only complaint was “some current decrease in sleep because he is anxious about getting out of the Army and finding a job”; and, the mental status exam was normal.  The MEB psychiatric examiner concluded, “While SM [service member] was diagnosed and treated for PTSD in the past he does not currently have PTSD or any other Axis I disorder that would render him unfit for military duty.  Therefore, SM is psychologically fit for military duty.”  The commander’s statement lauded the CI’s performance (within the constraints of his physical profile) as “excellent” and made no reference to any MH condition or impairment.

The Board directed attention to its recommendation based on the above evidence.  Under guidelines of the MH Review Project, there is no evidence that any MH diagnosis was unfavorably changed or unfairly eliminated; thus, this case does not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board then turned to its assessment of the fairness of the PEB’s determination that the PTSD condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the reasonable doubt standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The MEB psychiatric opinion, the absence of significant psychiatric symptoms or treatment at the time of separation, the S1 profile, and the lack of implication of any MH-based performance limitations by the commander are compelling arguments opposing a conclusion that any MH condition can be reasonably recommended as unfitting.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for PTSD.

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, the Board unanimously recommends a disability rating of 10%, coded 5259, IAW VASRD §4.71a.  In the matter of the contended PTSD 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Surgical Residuals, Meniscal Injury, Right Knee 	5259	10% 	
Post-Traumatic Stress Disorder	Not Unfitting	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150006406 (PD201300776)

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 10% 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		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA