RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02318
BRANCH OF SERVICE:  Army	BOARD DATE:  20140814
SEPARATION DATE:  20041028

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army Reserve MSG/E-8 (88M/Motor Transport Operator) medically separated for chronic bilateral knee pain.  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 bilateral knee degenerative joint disease condition characterized as existing prior to service and 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 bilateral knee pain, with chronic right anterior cruciate ligament (ACL) deficiency” as unfitting, rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 CI.  The rating for the unfitting chronic bilateral knee pain, with chronic right ACL deficiency condition is addressed below and, 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 disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand 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 20040909	VA* - (4 Years 1 Months Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain, with Chronic Right Anterior Cruciate Ligament Deficiency 	5099-5003	10%	Left Knee Degenerative Joint Disease	5003-5260	10%	20080915	
			Right Knee Degenerative Joint Disease	5003-5260	10%	20080915	
Other x 0 (Not in Scope)	Other x # (Not in Scope)		
Combined:  10%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20081218 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Chronic Bilateral Knee Pain, w/Chronic Right Anterior Cruciate Ligament Condition.  The Board undertook an evaluation of the bundled knee pain conditions.

The goniometric range-of-motion (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.

DOS 20041028
Knee ROM
(Degrees)	PT ~ 11 Mo. Pre-Sep
(20031105)	MEB ~ 04 Mo. Pre-Sep
(20040622)	VA C&P ~ 4 Years Post-Sep
(20080710)	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	--	130	117	120	48	90	
Extension (0 Normal)	--	0 	0	0	0	0	
§4.71a Rating DOS	--	0%	--	0%	10%	0%	
§4.59 Rating DOS	--	10%	--	10%	10%	10%	

Chronic Pain Right Knee.  The CI had a right knee condition aggravated by the physical demands of active duty occurring without trauma.  On 22 June 2004, the orthopedic narrative summary (NARSUM) physician noted a slow gait with slight pain arising from a chair during his examination.  He described a ROM as noted in the chart above, with stability in all four directions to stress with pain limiting motion.  The orthopedic test for integrity and function of the ACL (Lachman test) was Graded 1A (best possible result with no evidence of joint looseness and a good healing with tight end point to motion).  The orthopedic surgeon noted minimal grind and mild to moderate joint line tenderness and recorded X-ray image results of the right knee with peaking of the boney attachment where the forward and backward stabilizing ligaments attach.  The NARSUM surgeon also reported magnetic resonance imaging (MRI), showing a tear of the cartilage cushion on the inside back of the knee and a deficiency of the forward stabilizing ligament of the right knee.  The NARSUM stated that the CI was unable to walk or run without pain and could not carry a ruck sack or ambulate more than 3 blocks.  The VA C&P was completed 4 years after separation, and the Board determined this to be too remote for determination of knee function at separation.

The Board considered whether the chronic right knee pain condition was unfitting.  The Board noted the right knee condition was listed as the medical condition in the final physical profile prepared 4 November 2003.  The commander’s comment, dated 4 March 2004, stated the right knee arthritis condition prevented him from reasonably performing his duties.  The NARSUM, dated 22 June 2004, listed the right knee pain condition as a condition rendering the CI unable to meet his mission requirements and unfit for retention.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that the record reasonably supported the right knee condition to be unfitting upon unbundling from the left knee condition.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the bilateral knee pain condition using codes 5099-5003 (chronic joint disease) rated alternatively as degenerative arthritis, ruling a rating of 10% using the USAPDA pain policy.  The VA rated the right knee condition 10%, coded 5260 (leg, limitation of flexion), for painful motion.  The Board considered using code 5260 or 5261 (leg, limitation of extension) noting that the threshold for a rating could not be achieved with the ROMs in evidence.  There was no “frozen” knee to suggest use of code 5256 (ankylosis).  There was no instability of the knee in evidence to recommend the use of code 5257 (instability).  The cartilage cushion tear at the back of the right knee noted from the MRI was neither implicated in producing instability, locking or giving way of the right knee or surgically corrected, to permit use of respective codes 5258 (dislocated semilunar cartilage) or 5259 (symptomatic removed semilunar cartilage).  The Board unanimously agreed that using code 5003 (degenerative arthritis) IAW §4.59 and §4.71a could recommend a rating no higher than 10% for pain limiting motion of the joint.

Chronic Pain Left Knee.  The service treatment record (STR) shows the CI had knee pain from the increased activity required by activation to active duty.  The CI’s first clinic visit recorded for his left knee was on 20 May 2003.  He was authorized crutches during the period to rule out a stress fracture.  He presented to his therapy session on 14 August 2003 without crutches having left them in his car, which he had taken to the shop.  He completed the physical therapy course on 6 November 2003 and was discharged from therapy sessions having a ROM for the right more painful knee as recorded in the chart above and a mildly painful gait without crutches.  Range-of-motion for the left knee was not recorded at the final therapy clinic visit.  The left knee pain was not listed in the final permanent profile written by the NARSUM orthopedic surgeon as an activity limiting condition.  The commander’s comments did not describe the left knee pain as affecting the CI’s ability to reasonably perform his mission requirements.  X-ray imaging of the left knee obtained on the day of the NARSUM examination showed only peaking of the boney attachment of the forward and backwards stabilizing knee ligaments.

The Board next considered whether the chronic left knee pain condition was unfitting.  No order for a left knee MRI was in evidence throughout the STR.  The majority of the STRs addressed only the right knee.  The left knee, when mentioned, was described as being less painful than the right.  The final permanent profile listed only the right knee as the limiting medical condition.  The commander’s comments made no mention of a left knee condition affecting his ability to do mission required tasks.  After due deliberation, the Board concluded that the record did not support finding the left knee condition as reasonably justified as separately unfitting when unbundled from the right knee condition and not subject to rating.  In summary the Board recommends 10% for the right knee condition and no rating for the not unfitting left knee condition for a total of 10%.  This provides no rating benefit to the CI and the Board, therefore, recommends no change to the PEB’s rating determination.

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 chronic bilateral knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic bilateral knee pain condition and IAW VASRD §4.59 and §4.71a, the Board unanimously recommends no change in the PEB’s 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 20131112, 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 XXXXXXXXXXXXXXX, AR20150002962 (PD201302318)

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