RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	 	CASE: PD-2013-02132
BRANCH OF SERVICE:  ARMY		BOARD DATE:  20140527
SEPARATION DATE:  20050526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (96B/ Intelligence Analyst) medically separated for a chronic left knee condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB characterized his condition as left knee retro-patellar pain syndrome (RPPS).  The MEB also identified and forwarded “panic attacks” but determined this condition to have existed prior to service (EPTS).  Both conditions were forwarded to the Physical Evaluation Board (PEB) for adjudication.  The Informal PEB adjudicated the left knee condition as “chronic left knee pain and decreased motion” unfitting and rated it at 20%.  The mental health condition was determined to be EPTS and was not rated.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My range of motion and physical activity has been significantly reduced due to my service-connected disability.  I am no longer able to run for distances greater than 0.5 mile due to extreme pain.  In the workplace, I have to constantly ascend and descend staircases which also causes pain.  This has increased since my original separation from service in 2005.  Both knees now have a continuous “pop” when I walk.” 

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 chronic left knee condition is addressed below; no additional conditions are within the Board’s defined DoDI 6040.44 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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20050513	VA - (Exam ~ 11 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain and Decreased Motion	5258-5261	20%	Patellofemoral Syndrome, Left Knee	5260	10%	20060420	
Other x 0 (Not in Scope)	Other x 4	20060420 	
Combined:  20%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20060519 (most proximate to date of separation [DOS]).

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 member’s career, and then only to the degree of severity present at the time of separation.  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 the VA Schedule for Rating Disabilities (VASRD) standards, based on severity at the time of separation.

Chronic Left Knee Condition.  The CI presented in mid-August 2004 with a one-day history of pain after running.  He was noted to have a normal examination including full range-of-motion (ROM).  Conservative management was not successful.  On 29 October 2004, he was evaluated in primary care and found to have a bilaterally positive patellar grind test, consistent with RPPS, and lateral (outside) joint line tenderness on the left, suspicious for a tear of the lateral meniscus.  The examination was otherwise unremarkable including ROM which was 0-135 degrees bilaterally.  Knee X-rays were normal.  When seen 2 weeks later in physical therapy, his gait and ROM (0-140 degrees) were normal.  The diagnosis of bilateral RPPS was continued.  The CI was seen in orthopedics on 3 January 2005 and noted to have near normal ROM (0-130 degrees bilaterally), stable ligaments, a normal gait, positive patellar grind (a provocative test for RPPS) and positive testing for a left lateral meniscal tear (LMT).  A magnetic resonance imaging (MRI) accomplished on 25 February 2005 was suspicious for a medial meniscal tear (MMT) of the left knee.  At the MEB examination on 28 February 2005, the CI reported a left knee injury.  The examiner noted a positive patellar grind and signs of left lateral meniscal irritation.  A follow-up orthopedic consult on 4 March 2005, 2.5 months prior to separation, noted a positive grind and the CI was thought to have a LMT on the left clinically (not seen on MRI) and to not have clinical evidence for the possible MMT observed on MRI.  The CI was issued a L3 profile for bilateral knee pain; an MEB had been initiated for the panic disorder.  The narrative summary was dated 20 April 2005, but referenced the physical examination conducted on 28 February 2005.  The examiner noted that the CI requested an MEB during an orthopedic evaluation on 4 March 2005 as he was being “chaptered” for the panic disorder.  It also referenced a note from the orthopedic clinic to the MEB stating that the CI had declined surgery secondary to his psychological diagnosis and concern that he would not be able to endure it.  The ROM was noted to be 15-115 degrees, lacking 15 degrees of extension and 25 degrees of flexion and consistent on repetition.  He was noted to be wearing a knee immobilizer.  His knee was stable; signs of meniscal irritation persisted.  The left RPPS condition was determined to fail retention standards.  The panic attack disorder was determined to be EPTS (existed prior to service) and to meet retention criteria.  The MEB considered the same diagnoses and made the same determination.  The PEB on 13 May 2005, 2 weeks prior to separation, determined that the chronic left knee pain was unfitting and rated it at 20% for loss of extension (15 degrees) using the codes 5258 and 5261, dislocation of the meniscus and limitation of extension, respectively.  At the VA Compensation and Pension (C&P) examination performed on 20 April 2006, almost 11 months after separation, the CI reported pain that “comes and goes.”  He denied locking, but noted that it occasionally gave way.  He used no aids for ambulation, but occasionally wore a brace.  On examination, he had full extension and flexion limited to 110 degrees.  The knee was stable without tenderness or signs of meniscal irritation.  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.

Left Knee ROM
(Degrees)	Ortho ~2 Mo. Pre-Sep	MEB ~1 Mo. Pre-Sep	VA C&P ~11 Mo. Post-Sep	
Flexion (140 Normal)	130	15-115	110	
Extension (0 Normal)	0	Lacks 15 of full ext	0	
Comment	Nml Gait; stable	Wearing knee immobilizer	Examination benign otherwise	
§4.71a Rating	10%	20%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  All ROM measurements except that done for the MEB, documented normal extension and flexion which ranged from normal to 30 degrees less than full, a loss which is non-compensable.  The loss of extension was not supported at any other examination.  The examination and MRI were not consistent with each other regarding the presence of a meniscal injury and the VA C&P examination was negative for signs of meniscal irritation.  The Board found no route to support a rating higher than 10%, less than the 20% rating adjudicated by the PEB.  However, the Board does not recommend a rating less than that adjudicated by the PEB.  Therefore, 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 left knee 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.  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 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131028, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150002605 (PD201302132)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA