RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-01390
BRANCH OF SERVICE:  Army	BOARD DATE:  20140820
SEPARATION DATE:  20041012

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Private First Class/E-1 (Recruit) medically separated for a left knee condition which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and was referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “left knee pain, patellofemoral pain syndrome,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic left knee pain secondary to chondromalacia of the patella … s/p (status post) partial meniscectomy” as unfitting, rated 0%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “VA rated my disability at 20%.”

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 left knee condition is addressed below; no additional conditions are within the DoDI 6040.44 defined 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.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting Service disability determinations.  The Board’s role is thus confined to the review of medical records and available evidence to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20040922	VA (7 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain...(Residuals)	5099-5003	0%	Left Knee...Sprain (Residuals)	5258	20%	20050512 	
Other x 0 (Not in Scope)	Other x 0		
Rating:  0%	Rating:  20%	
Derived from VA Rating Decision (VARD) dated 20050920 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Knee Condition.  The service treatment record (STR) notes an onset of left knee pain in June 2004 and the narrative summary (NARSUM) dated 26 August 2004 documents that this was not associated with a discrete injury (although conflicting entries suggest an injury during training).  Entries over the ensuing weeks document persistent pain, swelling and complaints of “locking” of the joint.  Magnetic resonance imaging (MRI) in July 2004 demonstrated a partial tear of the lateral meniscus and mild chondromalacia [injury or wear of the cartilage under the knee cap], but was otherwise normal with no additional meniscal involvement and intact ligaments.  The CI underwent an arthroscopic meniscectomy 2 weeks later (3 months prior to separation).  There are various STR entries documenting normal gait and none documenting weakness or instability.
The NARSUM was prepared 6 weeks after surgery, with no interim post-operative STR entries, and is excerpted below.
“Upon returning [from post-surgical convalescent leave], she had no further clicking in the medial aspect of her knee but was unable to return to intensive walking activities, running or bicycling secondary to pain in the anterior aspect of her knee.  She states that her condition is made worse with jumping, trying to run, walking more than 2 miles and long sets of stairs. ... She denies any swelling. ... At this time, she is not tolerating advancement to full activities.”
The NARSUM physical exam (by an orthopedist) was comprehensive, noting a patellar grind (consistent with chondromalacia) as the only positive finding.  It documented the absence of joint line tenderness, effusion, instability to stress testing in all planes and signs of cartilage impingement (negative McMurray and Apley signs).  The range-of-motion (ROM) was flexion to 140 degrees (normal).

There is one physical therapy note in the STR from September 2004 (after the NARSUM, 5 weeks prior to separation) which states “popping gone/clunking gone” (indicating pre-operative signs of loose cartilage had resolved); it also documents a normal gait with “mild” tenderness as the only positive finding, with no documentation of effusion, cartilage signs or instability.

The VA Compensation and Pension evaluation (7 months after separation, examiner was not an orthopedist) states,  “The patient reports that since the surgery she has had ongoing problems with pain, weakness, stiffness, swelling, locking up of the left knee, and lack of endurance.”  The CI characterized the locking as “locks up with prolonged standing.”  She rated her pain (“not constant”) at 4-5/10, with exacerbations to 7/10 during the locking episodes which “lasts for a few minutes until she is able to unlock the knee.”  The VA physical exam noted a normal gait, tenderness and crepitus, without mention of swelling or effusion and “no ligamentous laxity,” but a positive McMurray’s sign (suggestive of cartilage impingement, examiner dependent).  The VA ROM measurements were flexion 150 degrees and extension 0 degrees (normal).  An MRI from the VA (8 months after separation) demonstrated changes interpreted as “a small tear versus prior surgery.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB’s recommended 0% rating determination was “Rated as degenerative arthritis [analogous 5003] without loss of joint motion.”  Although under the VASRD §4.71a stipulation of “2 or more major joints,” a single joint does not meet the minimum 10% rating criterion, this coding approach skirts application of VASRD §4.59 (painful motion) or §4.40 (functional loss) and does not defer to §4.7 (higher of two evaluations) with regard to more favorably rated joint codes (applicable in this case as elaborated below).  In the absence of ROM impairment or instability, the only two specific joint codes providing for a compensable rating in this case are 5259 (cartilage, semilunar, removal of, symptomatic) and 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint).  The VA’s 20% rating under 5258 was premised on the specific history of locking as elaborated by the CI to the VA examiner, and correlated with the McMurray’s physical finding.  The VA imaging evidence also suggests the possibility of continued meniscal pathology which could result in locking.  Members deliberated extensively as to whether the higher 5258 rating was supported, since there was a paucity of objective evidence in the file supporting the requisite criterion of frequent locking at separation; but all members ultimately agreed that the locking criterion should be fairly conceded under VASRD §4.3 (reasonable doubt) considering the totality of the evidence.  Having so decided, the Board recommends a 20% rating for the left knee condition under code 5258.

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 left knee condition, the Board unanimously recommends a disability rating of 20%, coded 5258 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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chondromalacia and Residuals of Meniscectomy, Left Knee	5258	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130911, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXX
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, AR20150003018 (PD201301390)

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 20% 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