RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00097
BRANCH OF SERVICE:  Army	BOARD DATE:  20150130
SEPARATION DATE:  20060428

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Unit Supply Specialist) medically separated for bilateral knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Status post left anterior cruciate ligament (ACL) reconstruction in April 2005 and arthroscopic debridement in October 2005 with continued left knee pain” and “partial anterior cruciate ligament (ACL) tear right knee with continued right knee pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (low back pain) for PEB adjudication.  The Informal PEB adjudicated “chronic left knee pain with some loss of joint motion” and “chronic pain right knee” as unfitting, rated 10% and 0% respectfully, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “MEMBER mobility of Legs WERE Limited due to injuries, changed type of work field member could apply for after discharge.  Service member was young age when injured, which affected her career growth in a physical job.  Injuries limited mobility in daily activities due to inflammation, flexion + extension issues.”

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 conditions 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/Naval 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 Veterans Affairs Schedule for Rating Disabilities (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:

Service IPEB – Dated 20060414 | VA* (~2 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Left Knee Pain | 5099-5003 | 10% | Left Anterior Cruciate Ligament and Medial Meniscus Tears | 5003-5261 | 10% | 20060626
Chronic Pain Right Knee | 5099-5003 | 0% | Partial Right Anterior Cruciate Ligament Tear | 5257 | 10% | 20060626
Other x1 (Not In Scope) | Other x 6
RATING:  10% | RATING:  20%
*Derived from VA Rating Decision (VARD) dated 20060808 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  

Left knee.  The CI injured her left knee during a physical fitness event in February 2005.  The initial plain film X-rays were normal; however, a magnetic resonance imaging (MRI) study revealed a torn ACL.  She underwent arthroscopic repair in April 2005 with post-operative physical therapy (PT).  Her had continued pain and restricted range-of-motion (ROM) and had a second arthroscopic procedure to remove adhesions in October 2005.  The orthopedic addendum prepared 4 months prior to separation noted the CI underwent intensive PT, regained much of her motion, and was doing fairly well with the left knee at that time.  The physical exam findings are summarized in the chart below.  The narrative summary (NARSUM) prepared a month prior to separation noted that the CI reported her left knee extension improved, and she felt that she was progressing pretty well until she suffered an injury to her right knee in November 2005.  She noted some degree of left knee swelling in response to increased activity with no noticeable instability.  The NARSUM examiner referred to the detailed orthopedic exam contained in the orthopedic addendum.  Three months prior to separation the CI had ROM measurements performed by PT which are summarized below.  The VA Compensation and Pension (C&P) exam performed 2 months after separation was missing from the evidence present for review; however, the pertinent physical exam findings were documented in the VARD which is present for review and are summarized in the chart below.

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.

Left Knee ROM (Degrees) | Ortho Addendum 4 Mo. Pre-Sep | PT 3 Mo. Pre-Sep | VA C&P ~2 Mo. Post-Sep
Flexion (140 Normal) | 135 | 112 | 140
Extension (0 Normal) | 3 | 0 | 5
Comment | Normal gait; Decreased quad strength | - | No instability; Pos. Deluca criteria
§4.71a Rating | 10% (PEB 10%) | 10%* | 10% (VA 10%)
*IAW VASRD §4.40, Functional loss

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left knee pain condition by applying the analogous VASRD code 5099-5003, degenerative arthritis, and rated it 10% citing “some loss of joint motion.”  The VA applied a combination code of 5003-5261 (limitation of leg extension) and also rated it 10%.  The Board noted that a limitation of 10 degrees extension is required for the 10% rating under code 5261 which was not present in this case (a limitation of 5 degrees extension was documented in the C&P exam).  All exams proximate to separation document non-compensable ROM measurements and there was no post-surgical impairment that would allow for the application of any knee specific VASRD code.  The service treatment record evidence does support the presence of limited motion caused by swelling that was responsible for some functional loss.  Analogous coding is required as the left knee MRI did not demonstrate any degenerative changes.  There is no evidence supported route to a rating higher than 10% in this case.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the left ACL and medial meniscus tear condition was appropriately recommended in this case.

Right knee.  The orthopedic addendum prepared 4 months prior to separation noted that since the left knee surgery in October, the CI had an episode where she twisted her right knee in late November and had swelling and a large amount of pain.  She underwent an MRl on 29 November 2005·which revealed what appeared to be a partial ACL tear and possible meniscus tear.  Since then, she had continued rehabilitation.  She was able to use the right knee and progressed with ROM and strength, but had episodes of feeling like the knee gave out.  She did not wish to undergo any surgery for the right knee, and wished to treat it conservatively.  The physical exam findings are summarized below.  The NARSUM prepared a month prior to separation noted that her right knee stayed swollen and she did note some subjective right knee instability with no definite locking.  The NARSUM examiner referred to the detailed orthopedic exam contained in the orthopedic addendum.  Three months prior to separation the CI had ROM measurements performed by PT which are summarized below.  The C&P exam performed 2 months after separation was missing from the evidence present for review; however, the pertinent physical exam findings were documented in the VASRD which is present for review and are summarized in the chart below.

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.

Right Knee ROM (Degrees) | Ortho Addendum 4 Mo. Pre-Sep | PT 3 Mos. Pre-Sep | VA C&P ~2 Mo. Post-Sep
Flexion (140 Normal) | 130 | 122 | 140
Extension (0 Normal) | 0 | 0 | 0
Comment | Normal gait; Minimal effusion; Mild instability; Decreased quad strength | - | No instability; No Deluca criteria
§4.71a Rating | 10% (PEB 0%) | 10%* | 10%* (VA 10%)
*IAW VASRD §4.40, Functional loss

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left knee pain condition by applying the analogous VASRD code 5099-5003 (degenerative arthritis) and rated it 0% citing “Rated as analogous to degenerative arthritis without loss of joint motion.”  The VA applied code 5257 (other impairment of the knee recurrent subluxation or lateral instability) and rated it 10% consistent with “slight.”  All exams document non-compensable ROM measurements.  The evidence supports that the CI had at least a partial right ACL tear and did not undergo and surgical correction.  She experienced subjective instability and the orthopedic specialist’s examination documented “mild instability.”  Rating using code 5257 requires application of the subjective criteria of slight, moderate, or severe for the 10%, 20%, or 30% rating respectively.  In keeping with the subjective instability the CI experienced and the “mild instability” documented by the orthopedic specialist, Board members agree that the CI’s right knee instability was best described as “slight.”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the Board recommends a disability rating of 10% for the partial right ACL tear 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 left ACL and medial meniscus tear condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the partial right ACL tear condition, the Board unanimously recommends a disability rating of 10%, coded 5257 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:

CONDITION | VASRD CODE | RATING
Left Anterior Cruciate Ligament and Medial Meniscus Tears | 5299-5003 | 10%
Partial Right Anterior Cruciate Ligament Tear | 5257 | 10%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140122, 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 XXXXXXXXXXXXXXX, AR20150008496 (PD201400097)

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 20% 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		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-00097