RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02404
BRANCH OF SERVICE:  Army	BOARD DATE:  20150108
SEPARATION DATE:  20070118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (74D/Chemical, Biological, Radiological and Nuclear Specialist) medically separated for a right knee condition which could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS) or physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The knee condition, characterized as “patellofemoral syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded six other conditions (right hip pain, migraine headaches, pituitary adenoma, tenosynovitis of the right wrist, infertility and gastroesophageal reflux disease) for PEB adjudication.  The PEB adjudicated the right knee condition as unfitting, rated 0%, referencing the US Army Physical Disability Agency (USAPDA) policy referring to analogous codes.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I acquired injuries in Iraq, combat related injuries.”

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.  None of the conditions adjudicated as not unfitting by the PEB were combat related injuries; thus, none fall within the DoDI 6040.44 defined purview of the Board.  The Board notes that the right hip condition (included with above) was documented as failing retention standards in the MEB narrative summary (NARSUM) and profiled, although designated as medically acceptable on the MEB’s DA Form 3947 and the PEB’s DA Form 199, was subsequently addressed by a PEB addendum.  That and all remaining conditions are eligible for consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20061003	VA – No VA Rating Decision (VARD)*	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Patellofemoral Syndrome	5099-5003	0%	* A pre-separation VA Compensation and Pension (C&P) examination dated 20060501 is in evidence; but, the VARD was unavailable based on a letter dated 20131203 from the VA Louisville Regional Office.  Likewise, there is no other probative post-separation VA evidence in evidence.  
	
Other x 0 (Not in Scope)		
Rating:  0%	Rating:  Unknown	

ANALYSIS SUMMARY:  The Board acknowledges the missing VARD evidence as above; but, it was judged by the members that the available evidence from the service treatment record (STR) and prior to separation VA C&P examination is sufficiently probative for fair adjudication; and, that any missing evidence would not materially affect the Board’s recommendations.  It is emphasized that Board recommendations are premised on rating IAW the VA Schedule for Rating Disabilities (VASRD) based on the disability in evidence at the time of separation.  Additional delay in further (and likely futile) attempts to retrieve this evidence was thus considered to be unwarranted.

Right Knee Condition.  The earliest entry in the STR from July 2005 documents a week of right knee pain and the CI’s statement that she did not “know what happened to make this pain start.”  She was already undergoing physical therapy (PT) for right hip/sciatica pain and knee therapy was added to the treatment plan.  X-rays were normal and the PT diagnosis was retro-patellofemoral pain syndrome (RPFS).  A PT note in March 2006 (10 months prior to separation) documented knee pain rated 6/10, a normal gait, and flexion to 135 degrees (normal 140 degrees; minimum compensable 45 degrees).  The provider noted that maximal benefit from PT had been achieved; and, discharged the CI from PT, recommending a permanent profile.  An orthopedic note a week later documented knee tenderness without swelling or effusion, no signs of cartilage impingement, stability to stress testing in all planes, and “full” range-of-motion (ROM).  The orthopedist concurred with the diagnosis of RPFS and recommended a MEB.  There are a few STR entries leading up to separation which document continued pain with no significant changes from the above course.  There are no STR entries documenting abnormal gait, significant ROM limitation, instability, signs of cartilage impingement, locking, or persistent effusions.  Although she was able to perform an alternate physical fitness test, she could not meet the requirements of her MOS.

The VA C&P examination (8 plus months prior to separation) referenced a 2005 knee injury not evidenced in the STR; and, documented daily pain rated 7/10 exacerbated by “exercise, prolonged standing, [and] bending.”  The VA physical exam noted a normal gait, no tenderness, no instability or signs of cartilage impingement, and recorded ROM measurements of 140 degrees flexion and 0 degrees (normal) extension.  The NARSUM was conducted in August 2006 (6 months prior to separation); and, noted “frequent” pain rated 5/10 and “occasional swelling of the knee joint with overuse;” with limitations on load bearing, prolonged standing, running, and stair climbing.  The physical exam noted tenderness, stability to stress testing, no signs of cartilage impingement (locking), and full flexion to 140 degrees with specific notation of pain at 80 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating analogous to 5003 (degenerative arthritis) rested on application of the USAPDA policy referring to analogous codes, which did not address VASRD §4.59 (painful motion).  The NARSUM examination explicitly documented painful motion beginning at mid-flexion, and the minimum 10% rating is thus supported by the provisions of §4.59.  There is no evidence for compensable ROM impairment, frequent effusions, or locking which would support a rating higher than 10% under any applicable code; and, no grounds for additional rating of instability.  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 5024 (tenosynovitis) for its clinical compatibility with the diagnosis.

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 policy for rating was operant in this case, and it was adjudicated independently of that policy by the Board.  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5024 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	
Retro-Patellofemoral Pain Syndrome, Right Knee	5024	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131114, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

			
XXXXXXXXXXXXXXXXX
President
DoD 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, AR20150007449 (PD201302404)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA