RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300543
BRANCH OF SERVICE:  Army	BOARD DATE:  20140228
SEPARATION DATE:  2008102

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63B1O/Wheeled Vehicle Mechanic) medically separated for a right knee condition.  The CI entered the Active Duty Army in 2007 and deployed to Iraq where he reported gradual onset of right knee pain that worsened.  He was redeployed and underwent repeat arthroscopy in 2008 according to the Physical Evaluation Board (PEB) proceedings document.  Unfortunately, the right knee pain 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 right knee pain condition, characterized as “Right Patellofemoral Dysfunction…” was forwarded to the PEB as not meeting medical standards IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “leg, limitation of extension, right” as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “My injuries were exacerbated and made worse while serving in Iraq causing me to be MEDVACED out of country.  I have since undergone several surgeries and have been forced to have a replacement.”

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.  The back and abdomen conditions, as per the contention, were not identified by the PEB; and, thus are not within the DoDI 6040.44 defined purview of the Board.  These, and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected conditions continue to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate service members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.

RATING COMPARISON:

Service IPEB – Dated 20080822	VA* - (Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Leg, Limitation of Extension, Right	5261	10%	ACL Strain Right Knee*	5237*	NSC*	STR	
No Additional MEB/PEB Entries	Other x 6	STR	
Combined:  10%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20090505 (most proximate to date of separation (DOS))
Condition changed to right knee chondromalacia patella, coded 5099-5014 and rated 10% effective 20091105 by VARD 20100503, based on C&P exam 20100409

ANALYSIS SUMMARY:

Right Leg Limitation of Extension:  The CI had a heavy object strike his right knee in November 2002 and he subsequently developed anterior, retropatellar knee pain with crepitence, buckling and intermittent “locking.”  In 2003, the CI had a normal magnetic resonance imaging (MRI) scan.  In spite of extensive physical therapy, his right knee pain continued and the CI underwent arthroscopic surgery in November 2005.  The operation report documents a strain of the right anterior cruciate ligament (ACL); no meniscal injury; with poor tracking of the patella; so a lateral patellar release was performed.  After rehabilitation, the CI’s knee pain resolved.  In May 2007, the CI entered active service and was deployed to Iraq in October 2007 where his right knee pain returned after the increased activity.  There was no documentation of a new injury.  In March 2008, he was redeployed home due to the knee pain which was described as a dull achy retro-patellar pain, 5/10 in intensity with intermittent locking and buckling.  The pain prevented him from running, jumping, kneeling or heavy lifting and was somewhat relieved by rest.  The CI was offered repeat arthroscopy but there is no evidence that the procedure was actually performed.  He had another MRI study in May 2008 that revealed a small area of lost cartilage on the undersurface of the patella but was otherwise unremarkable.  The MEB physical exam, performed approximately 3 months prior to separation, documented right knee tenderness, no swelling and normal extension with slightly limited flexion.  At the MEB narrative summary (NARSUM) exam, approximately 2 months before separation, the CI reported being prescribed narcotic medication for the pain (which he was not using at that time) and continued intermittent locking and buckling about two to three episodes per day (there was no independent STR evidence to support knee locking/buckling).  The physical exam findings are summarized in the chart below.  The VA’s initial rating decision for the “Anterior Cruciate Ligament Strain of the Right knee” as “not service-connected” was based on STRs dated 17 May 2007 to 20 October 2008.  The CI had a VA Compensation and Pension examination performed approximately 18 months after separation (the physical exam findings are summarized in the chart below), and based on that exam, the VA granted service-connection for the right knee condition and rated it 10%, effective 5 November 2009.  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.

					DOS: 20 October 2008
Right Knee ROM (Degrees)	PT 7.3 Mo. Pre-Sep	NARSUM 2.5 Mo. Pre-Sep	VA C&P 17.9 Mo. Post-Sep	
Flexion (140 Normal)	“Full” ROM	90	130	
Extension (0 Normal)	“Full” ROM	10	0	
Comment	Antalgic gait; Normal meniscus; Pos. tenderness to palpation (TTP) of patellar boarder; Hypermobile patella	Mild swelling to peri-patellar area; Pos. TTP medial joint line; Neg. evidence of instability; No DeLuca criteria	Patella tracks in midline; No effusion; No atrophy; No evidence of instability; No joint line tenderness; Mildly symptomatic medial plica	
The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the right knee condition by applying VASRD code 5261, limited extension of the leg, and rated it 10% based on the ROM measurements contained in the NARSUM.  The PEB proceedings document referenced a second knee arthroscopy that the Board was unable to substantiate with the records present for review.  Board members agreed the inability to substantiate the second arthroscopy would have no effect on its rating recommendation.  The VA initially did not grant service-connection to the right knee condition based on limited STR data; however, they ultimately rated the right knee condition as 10% disabling effective almost 13 months after separation.  The Board assigned highest probative value to the NARSUM exam as it was accomplished closet to separation, was comprehensive in nature, and adequately reflected the evidence present in the STR.  That exam documented a non-compensable flexion ROM measurement while the extension ROM measurement was properly rated at 10% by the PEB.  The Board reviewed the remainder of the record for independent evidence of locking or dislocation of the right knee but was unable to confirm the CI’s subjective history.  Additionally, the MRI findings of no meniscal injury and all physical exam findings do not support locking or dislocation that would allow for other knee specific coding options.  Alternative coding under VASRD code 5003, degenerative arthritis, would also result in a 10% rating (due to no documented incapacitating episodes) and confer no benefit to the CI.  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 “leg, limitation of extension, right” 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 “leg, limitation of extension, right” 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Leg, Limitation of Extension, Right	5261	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130519, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

SFMR-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 XXXXXXXXXXXXXXXXXX, AR20140009334 (PD201300543)

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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA