RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301590
BRANCH OF SERVICE:  Army	BOARD DATE:  20140730
SEPARATION DATE:  20090615 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty CPL/E-4 (94F/Special Electronic Device Repair) medically separated for a right knee condition.  The CI’s right knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was permitted to take the alternate Army physical fitness test (aerobic portion).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “right patellofemoral syndrome” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “right patellofemoral syndrome evaluated as arthritis, degenerative IAW the Table of Analogous Codes” as unfitting, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Chronic knee pain along with arthritis in knees and spine which was discovered by VA.  In addition service connected PTSD.”

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be 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 condition continues to burden him; but must emphasize that the Military DES has neither the role nor the authority to compensate 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 (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20090410 | VA - (1 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Right Patellofemoral Syndrome | 5099-5003 | 10% | Right Knee Sprain | 5260 | 10% | 20090512
No Service Entry | Anxiety Disorder NOS | 9413 | Defer* | 20090512
Other x 0 (Not in Scope) | Other x 0 | 20090512
Combined:  10% | Combined:  10%
Derived from VA Rating Decision (VARD) dated 20090727 (most proximate to date of separation [DOS]).
*VARD 20091125 denied service connection for DC 9413 (Anxiety Disorder NOS).  VARD 20130813 granted DC 9411 (PTSD), previously claimed as Anxiety Disorder NOS, rated 30% effective 20120108.

ANALYSIS SUMMARY:

Right Knee Condition.  The narrative summary (NARSUM) noted the applicant reported he experienced gradual onset of right knee pain in May of 2008 while deployed in Iraq.  In July 2008, he was diagnosed with right patellofemoral syndrome (PFS).  The CI was treated conservatively with medications and physical therapy (PT) with minimal efficacy.  He was prescribed a knee brace and crutches.  Theater clinic entry dated 6 August 2008, observed tenderness on ambulation, normal right knee flexion, tenderness to palpation at the superior pole of the patella and pain on extension.  There was absence of swelling, edema, signs of inflammation and no crepitus.  Orthopedic consultation on 15 August 2008, noted the CI’s report of a twisting injury to the right knee in May 2008.  Since the injury he experienced right knee locking, popping, swelling and giving away.  Examination of the right knee revealed no swelling, a normal neuromuscular examination, no evidence of instability and no tenderness to palpation.  Radiographs of the right knee dated 15 August 2008 showed no evidence of fracture or dislocation and no joint effusion.  Magnetic resonance imaging of the right knee on 9 September 2008, demonstrated a subchondral cyst and edema in the lateral aspect of the patellar groove without overlying chondral defect.  There was no evidence of joint effusion or meniscus tear and all ligamentous structures were intact.  Orthopedic treatment entry dated 15 August 2008, recorded right knee with full range-of-motion (ROM), no tenderness on palpation, no evidence of knee instability or inflammation and no pain elicited on motion.  The diagnosis of PFS was recorded.  At the follow-up orthopedic visit on 27 October 2008, the CI stated the pain was worse with prolonged walking and standing, going up and down stairs and with keeping knee in a flexed position over a period of time.  Physical examination recorded mild effusion to the right knee, grossly full ROM with no limitation in motion at the end of flexion or extension.  There was no evidence of knee instability.  The CI was deemed not to be a surgical candidate.  Orthopedic clinic entry dated, 6 February 2009 noted pain along the patellofemoral joint with no indication of instability and no pain on palpation over the joint lines.  The remainder of the knee exam was within normal limits.  The physician recommended an MEB.  At the 3 February 2009 orthopedic visit, the CI reported right knee joint swelling, that the right knee locked up and he was unable to straighten it.  On examination, there was no evidence of inflammation, crepitus or locking and no joint line tenderness.  Pain was noted with full extension.  His gait was antalgic and he used a cane.  The physician noted the CI has chronic PFS but was able to do push-ups and sit-ups.  At the NARSUM on 24 February 2009, the CI reported pain intensity at rest of 5/10.  He described the pain as sharp, stabbing and localized to the retropatellar area and around the right patella area.  His pain increased with activities such as prolonged standing greater than 40 minutes, running, jumping, or walking up stairs; rest provided some relief.  He denied any locking or buckling.  The physical examination was not available; however, the MEB H&P examination dated 27 January 2009, recorded right knee flexion of 105 degrees, no evidence of instability or inflammation and a normal neuromuscular examination.  At the VA Compensation and Pension exam 12 May 2009, approximately a month after separation, the CI reported daily pain in the medial aspect of the right knee, no locking, but noted frequent popping and clicking.  He reported intermittent swelling accompanied by increased pain.  The CI continued to use a cane for walking.  The examiner noted there was no evidence of swelling, instability, locking, grinding and no giving away.  There was painful limitation of motion and pain following repetitive motion.  Neurological examination was unremarkable.  Right knee flexion was 130 degrees and there was no decrease in ROM with repetitive testing.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated right knee pain condition (patellofemoral syndrome) at 10% analogously to degenerative arthritis code of 5099- 5003, for painful motion.  The VA rated the condition recorded as right knee sprain, at 10%, coded 5260, for painful motion.  A higher rating under the 5003 code requires compensable limitation of motion, evidence of incapacitating exacerbations, or knee instability.  On review of the records, the Board noted the ROM was not compensable under 5260, 5261, 5257 or 5258.  Most of the recorded ROMs were decreased; however, not to a compensable level.  There was no objective evidence of knee locking or frequent effusions to support the use of code 5258. The Board adjudged that the record did not support the application of VASRD §4.40 functional loss.  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 right knee condition.

Contended PEB Conditions.  The Board first reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the military DES.  The evidence of the available records showed the diagnosis of anxiety disorder during processing through the DES.  The diagnosis of anxiety disorder was recorded in the DD Form 2808, but was not recorded in the MEB, and not submitted to the PEB.  Therefore, at the time of processing through the DES the diagnosis of anxiety disorder was eliminated.  This applicant did appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board undertook a careful review of the record in evidence and noted the CI reported a history of panic attacks and anxiety that began at the age of 17.  The commander statement noted the CI was evacuated initially for “high anxiety issues;” however, stated the command had not observed anxiety issues in public settings or events; “he kept a quiet and low profile.”  The CI was evaluated once by psychology and reported he underwent pre-enlistment psychological assessment and was cleared.  Recommendations were made for him to follow-up for relaxation and skills building training; however, there was no indication of any further visits.  Psychology consult, dated 10 March 2009, stated the CI did not allege any “psych impairment” and that a review of primary care notes had made brief mention of anxiety; however, the CI “was not being treated for anxiety”.  The Board concluded, there was insufficient evidence to support that the CI met diagnostic criteria for any mental health condition.  The Board members agreed no diagnosis was changed or eliminated to the CI’s disadvantage.  The Board noted the condition of anxiety disorder NOS was claimed in November 2009 by the CI at the VA and was found not service-connected or aggravated by service.

The Board also found no evidence of treatment for any MH condition prior to separation.  There was no indication from the record that any MH condition significantly interfered with satisfactory duty performance.  No MH condition was profiled or implicated in the commander’s statement as related to negative impact on performance.  All Board members agreed the listing of the conditions on the MEB DD Form 2808 reflected reported symptoms that had not required treatment.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient evidence that any mental health condition rose to the level of unfitting at the time of separation and therefore none were subject to disability rating.

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 right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended mental health condition, the Board unanimously agrees that it cannot recommend it for disability rating.  There were no other conditions within the Board’s scope of review for consideration. 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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130921, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX, AR20140015973 (PD201301590)

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

PD1301590