RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-02719
BRANCH OF SERVICE:  Army	BOARD DATE:  20150603
Separation Date:  20060410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Indirect Fire Infantry) medically separated for a left knee disability.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for an Medical Evaluation Board (MEB).  Chronic left knee pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated the left knee condition as unfitting, rated 0% with likely application of AR 635-40 and 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:  He was given a higher rating from the VA.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any condition outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20060213	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5010	0%	Residuals, Internal Derangement Left Knee, S/P Meniscus Tear	5261	30%	20060615	
Pigmented Glaucoma	Not Unfitting	Bilateral Pigmentary Glaucoma	6013	10%	20060622	
Hypertension	Not Unfitting	Hypertension	7101	10%	20060615	
Cholesterol	Not Unfitting	Hyperlipidemia	7099-7005	NSC	20060615	
Other MEB/PEB Conditions x 0 (Not In Scope)		
RATING:  0%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20060821 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Chronic Left Knee Pain.  The CI slipped on ice and injured his left knee in December 2004.  He underwent weekly left knee physical therapy (PT) from February through April 2005 without any improvement.  The left knee MRI done in April 2005 showed slight cartilage thinning along the inner knee; however, there was no meniscal tear.  An orthopedic evaluation noted left knee pain and that no surgery was indicated.  The CI continued to have left knee pain with tenderness popping and intermittent numbness in his leg.  The DD Form 2808, Report of Medical Examination, dated 16 December 2005, dated 4 months prior to separation, documented “pain on palpation and ROM” for the lower extremity exam.  The MEB narrative summary (NARSUM) exam performed 3 months prior to separation documented continuous, chronic left knee pain.  The NARSUM physical exam documented flexion to 125 degrees (normal 140) and “full extension” with no change on repetition (cited range-of-motions (ROM) matched the PT evaluation).  A neurology evaluation performed 2 months after the NARSUM noted complaints of intermittent numbness and tingling in the feet and pain in both knees with the left worse than the right.  The physical exam showed normal motor exam in the lower extremities and slowed reflexes in the knees.  A left lower extremity nerve conduction study (NCS) done in March 2006 was normal.

The VA Compensation and Pension (C&P) exam completed 2 months after separation documented that the CI had functional limitations of an inability to stand longer than 30 minutes, an inability to walk more than one mile and difficulty with stair climbing.  The CI reported that his knees ached constantly on a pain scale of 6/10 with flares of 8/10 that lasted for several minutes, stiffness, weakness and moderate flares that occurred weekly and the knee joint would pop frequently.  He indicated he had an MRI that showed a torn meniscus.  The VA C&P physical exam documented a normal gait with tenderness, guarding and knee joint pops on bending.  There was difficulty balancing on the left leg (could balance on the right).   ROM was documented as “Extension:  Lacks 10 degrees from full knee extension w/ (with) pain from lacking 25 degrees to lacking 10 degrees.  The range of motion and joint function of the left knee is additionally limited by pain from lacking 25 to lacking 10 degrees of extension and from 117-125 degrees of flexion following repetitive use.”  [Of note, the right knee was similarly addressed with pain from lacking 22 to lacking 7 degrees of extension.]  X-ray of bilateral knees documented minimal degenerative changes of the right knee, but was normal for the left knee.  A NCS/electromyelogram (EMG) done on the left lower extremity in June 2006 was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic left knee pain condition as 5010 (arthritis, due to trauma, substantiated by X-ray findings) and rated at 0%.  The PEB disability description stated “essentially full range-of-motion and pain with motion” which was likely application of AR 635-40, B-29 which indicated “ratings for loss of joint motion can only be awarded where a mechanical basis for limited motion is found.”  The VA coded the residuals, internal derangement left knee, status post meniscus tear condition as 5261 (leg, limitation of extension of) and rated at 30% based on “extension limited to 20 degrees.”  The MEB and PEB noted painful motion which would warrant a 10% rating IAW VASRD §4.59 (painful motion) or consideration of the criteria under disability code 5003 “… limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10% is for application for each such major joint or group of minor joints affected …”  

The VA exam was closer to separation and was a more complete exam; however, the source ROM exam was written in a manner which may have been easily misinterpreted.  Evaluation of that exam indicated there was a painful arc from extension lacking 25 degrees to lacking 10 degrees with additional pain on repetition; the pain-limited ROM was adjudged as “lacks 10 degrees” and did not support the VARD’s interpretation of “lacking up to 25 degrees,” especially as the gait was documented as normal.  Knee extension lacking 10 degrees would rate 10% under code 5261 (or 5010 or 5003).  There was no objective evidence of knee instability for potential dual coding, and no frequent episodes of “locking” and effusion for alternative higher analogous meniscal rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition coded 5099-5010.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were pigmented glaucoma, hypertension and cholesterol.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is preponderance of the evidence but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

None of these conditions were profiled; none were implicated in the commander’s statement; and none were judged to fail retention standards.  All were reviewed and considered by the Board.  There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 pigmented glaucoma, hypertension and cholesterol contended conditions; and, therefore, no additional disability ratings can be recommended.

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 AR 635-40 for rating the knee condition was likely operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5010 IAW VASRD §4.71a.  In the matter of the pigmented glaucoma, hypertension and cholesterol contended conditions, the Board unanimously recommends no change from the PEB determinations 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:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain	5099-5010	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX 
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  XXXXXXXXXXXXXXXXXXXX, AR20150012734 (PD201302719)

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 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						      XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA