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AF | PDBR | CY2012 | PD2012 01198
Original file (PD2012 01198.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE : PD120 1198
BRANCH OF SERVICE: Army   BOARD DATE: 2013 0710
Separation Date: 20020504


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (91C/Licensed Practical Nurse) medically separated for a right knee problem. The CI began experiencing right knee pain in 1996 with no specific trauma. Despite four extensive arthroscopic surgeries, physical therapy (PT), and medication, the knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. The CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “right knee pain--the pain is frequent and slight; Grade IV chondromalacia trochlear; Grade IV chondromalacia lateral femoral condyle; and early degenerative changes of the right knee” to the Physical Evaluation Board (PEB). No other conditions were submitted by the MEB. The PEB adjudicated chronic right knee pain, due to post traumatic osteoarthritis and patellofemoral chondromalacia as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION : “Unable to run, leading to weight problems, causing BP issues Knee swells regularly and has required further medical attention. Arthritis in knee will lead to a early knee 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 and no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention either not requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


RATING COMPARISON :

Service IPEB – Dated 20020204
 VA C&P - (4.5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Right Knee Pain due to Post Traumatic Osteoarthritis and Patellofemoral Chondromalacia 5003 10% Post-Traumatic Degenerative Arthritis, Right Knee, Status Post (S/P) Arthroscopic Surgeries 5010 10% 20020918
No Additional MEB/PEB Entries
 Other x 3 20020918
Rating: 10%
 Combined Rating: 30%
Derived from VA Rating Decision (VARD) dated 20030702 ( most proximat e to date of separation [DOS]).


ANALYSIS SUMMARY : 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 Disability Evaluation System 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.

Chronic Right Knee Pain due to Post-traumatic Osteoarthritis and Patellofemoral Chondromalacia . There were three range - of - motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Right Knee ROM
 (Degrees)
MEB
~ 8 Mo. Pre-Sep
 MEB Addendum
~4 Mo. Pre-Sep
 VA C&P
~4.60 Mo. Post-Sep
Flexion (140 Normal)
 1 15 130* 100
Extension (0 Normal)
 -- 5 5
Comment
 Lateral femoral condyle tender to palpation (TTP); positive patellar grind; negative Lachman’s, McMurray’s, and pivot shift; sensation intact to light touch, motor 5/5; scars well healed Slight effusion *ROM compared with l eft knee 3-135 degrees; ligamentously stable; significant patellofemoral crepitus with ROM Ortho exam : pain medial, lateral joint lines and 1+ effusion; knee ligaments stable in varus, valgus, anterior, posterior , Lachman’s, pivot shift testing; + McMurray’s on medial, lateral joint lines; some retro patellar crepitus; grind test mild discomfort; strength 5/5 ; neurologically intact
§4.71a Rating
 10% 10% 10%
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T invalid font number 31502 he PEB invalid font number 31502 did not adjudicate invalid font number 31502 this condition invalid font number 31502 as invalid font number 31502 an invalid font number 31502 existing prior to service invalid font number 31502 condition invalid font number 31502 . invalid font number 31502 In invalid font number 31502 April 1997, an invalid font number 31502 orthopedic surgeon noted the 23 invalid font number 31502 - invalid font number 31502 year invalid font number 31502 - invalid font number 31502 old CI had previously had two right knee arthroscopies for meniscal problems at age 14 and 15 but had full activities afterwards. At that visit invalid font number 31502 , invalid font number 31502 the CI complained of swelling and retropatellar pain and examination showed 3+ effusion, stable ligaments, positive grind, minimal joint line tenderness, ROM from 5 to 110 degrees, and invalid font number 31502 X invalid font number 31502 -rays showed a medial osteophyte. Repeat invalid font number 31502 X invalid font number 31502 -rays in May 1999 documented minimal osteophytes with preservation of joint space. invalid font number 31502 invalid font number 31502 The CI underwent another right knee arthroscopy invalid font number 31502 in invalid font number 31502 May invalid font number 31502 1999 invalid font number 31502 invalid font number 31502 with trochlear microfracture chondroplasty. He invalid font number 31502 was invalid font number 31502 referred to physical therapy and invalid font number 31502 given an anterior cruciate ligament brace. invalid font number 31502 invalid font number 31502 The CI continued with right knee pain and invalid font number 31502 in September 1999, his ROM was limited to 0 to 90 degrees. invalid font number 31502 E invalid font number 31502 ffusion was present and the provider was able to drain 25cc of yellowish clear fluid. A invalid font number 31502 repeat invalid font number 31502 X invalid font number 31502 -ray invalid font number 31502 revealed osteoarthritis invalid font number 31502 of the knee joint invalid font number 31502 with invalid font number 31502 invalid font number 31502 joint effusion. invalid font number 31502 The CI sustained a twisting injury to the right knee in October 2000 invalid font number 31502 invalid font number 31502 and an invalid font number 31502 X invalid font number 31502 -ray invalid font number 31502 showed mild degenerative changes invalid font number 31502 with some calcification in a medial joint space. invalid font number 31502 In December 2000, t invalid font number 31502 he invalid font number 31502 o invalid font number 31502 rthopedist noted that the CI had already undergone three right knee arthroscopies and invalid font number 31502 he invalid font number 31502 continued invalid font number 31502 to have invalid font number 31502 pain invalid font number 31502 with invalid font number 31502 activity invalid font number 31502 . Examination note invalid font number 31502 d invalid font number 31502 mild effusion but no instability. invalid font number 31502 Although there is no permanent profile in the record dated December 2000, the treatment plan for this visit included a invalid font number 31502 P3 profile invalid font number 31502 and a invalid font number 31502 March 2001 invalid font number 31502 note stated a permanent profile had been written at the last visit. In March 2001, a mild effusion was present and ROM was 0 to 125 degrees. invalid font number 31502 In May 2001 invalid font number 31502 , invalid font number 31502 an invalid font number 31502 outpatient invalid font number 31502 orthopedic visit noted an injury invalid font number 31502 a invalid font number 31502 month prior with a fall with pain and locking of the right knee. The CI had since improved invalid font number 31502 , invalid font number 31502 but on invalid font number 31502 examination, invalid font number 31502 he still had a positive effusion, patellofemoral crepitus, invalid font number 31502 and tenderness invalid font number 31502 to palpation of the medial joint line invalid font number 31502 invalid font number 31502 and ROM invalid font number 31502 from invalid font number 31502 0 to 130 degrees. invalid font number 31502 X-rays invalid font number 31502 performed invalid font number 31502 that day documented invalid font number 31502 a spur medially on the femoral condyle, slight generalized joint space narrowing invalid font number 31502 invalid font number 31502 and a small effusion in the suprapatellar bursa invalid font number 31502 . invalid font number 31502 The provider also ordered a invalid font number 31502 right knee MRI invalid font number 31502 invalid font number 31502 which was invalid font number 31502 performed invalid font number 31502 invalid font number 31502 in August 2001 invalid font number 31502 invalid font number 31502 and it invalid font number 31502 revealed a torn and macerated lateral meniscus with a portion of the meniscus that invalid font number 31502 wa invalid font number 31502 s flipped into the lateral notch invalid font number 31502 . invalid font number 31502 It also showed a large trochlear osteophyte on the sagittal cut invalid font number 31502 . invalid font number 31502 The CI was invalid font number 31502 issued invalid font number 31502 a permanent L3 invalid font number 31502 p invalid font number 31502 rofile for right k invalid font number 31502 nee degenerative joint disease invalid font number 31502 . invalid font number 31502 The invalid font number 31502 c invalid font number 31502 ommander’s invalid font number 31502 s invalid font number 31502 tatement noted that the chronic right knee pain interfered with performing his MOS duties and he was deemed to create a burden for others in his section and this adversely impacted unit readiness. invalid font number 31502 The C invalid font number 31502 I was referred to invalid font number 31502 PT d invalid font number 31502 ue to chronic right knee pain. invalid font number 31502

An initial MEB invalid font number 31502 narrative summary ( invalid font number 31502 NARSUM invalid font number 31502 ) invalid font number 31502 was completed in September 2001, invalid font number 31502 8 invalid font number 31502 months prior to separation. No new invalid font number 31502 X invalid font number 31502 -rays were taken and the examiner noted the radiographic findings discussed above. The physical examination findings are noted in the chart above. The degree of knee extension is illegible in the NARSUM. However, t invalid font number 31502 he CI’s symptoms intensified with light activities of daily living and orthopedics decided to perform yet another arthroscopy. invalid font number 31502 Physical therapy measured right knee ROM at 5 to 125 degrees in early November 2001. invalid font number 31502 At that time, invalid font number 31502 the CI underwent a right knee invalid font number 31502 invalid font number 31502 diagnostic arthroscopy, partial synovectomy invalid font number 31502 , invalid font number 31502 an invalid font number 31502 d mechanical knee chondroplasty and the MEB was placed on hold. invalid font number 31502 invalid font number 31502 A NARSUM invalid font number 31502 a invalid font number 31502 ddendum invalid font number 31502 invalid font number 31502 completed invalid font number 31502 in late invalid font number 31502 December 2001 invalid font number 31502 , invalid font number 31502 invalid font number 31502 approximately invalid font number 31502 invalid font number 31502 4 invalid font number 31502 months invalid font number 31502 invalid font number 31502 prior to separation invalid font number 31502 , invalid font number 31502 invalid font number 31502 documented that at the time of this ex invalid font number 31502 am, the CI was invalid font number 31502 7 invalid font number 31502 weeks post-operative invalid font number 31502 and that he had lateral pain as well as some medial pain and patellofemoral pain related to activity. The CI was unable to run, jump or march, carry a invalid font number 31502 rucksack invalid font number 31502 and unable to perform knee benders, jogging invalid font number 31502 in place invalid font number 31502 , side straddle-step invalid font number 31502 , invalid font number 31502 or high jump. The examiner classified the right knee pain invalid font number 31502 b invalid font number 31502 y American Medical Association invalid font number 31502 guidelines as slight and constant. invalid font number 31502 invalid font number 31502 The examiner diagnosed the CI with right knee invalid font number 31502 post invalid font number 31502 - invalid font number 31502 traumatic invalid font number 31502 osteoarthritis and patellofemoral chondromalacia. invalid font number 31502 The examiner noted the presence on the invalid font number 31502 magnetic resonance imaging ( invalid font number 31502 MRI invalid font number 31502 ) invalid font number 31502 of lateral meniscus changes consistent with the previous meniscectomy and that the medial meniscus appeared to be well healed. invalid font number 31502 The NARSUM invalid font number 31502 a invalid font number 31502 ddendum invalid font number 31502 physical exam findings are summarized in the chart above. The VA Compensation and Pension (C&P) invalid font number 31502 invalid font number 31502 joint invalid font number 31502 exam invalid font number 31502 , completed invalid font number 31502 approximately invalid font number 31502 4 invalid font number 31502 months invalid font number 31502 invalid font number 31502 after separation invalid font number 31502 , invalid font number 31502 noted invalid font number 31502 the clinical history described above invalid font number 31502 . invalid font number 31502 It also reported persistent arthritis symptoms such as stiffness, recurrent effusions, pain in the joint line regions, and mechanical symptoms of giving way. The CI reported pain with going up and down stairs and with rotation or twisting rotational motions and pain in the medial aspect of the knee with pressure to that area. invalid font number 31502 An invalid font number 31502 X invalid font number 31502 -ray invalid font number 31502 invalid font number 31502 performed invalid font number 31502 at this exam invalid font number 31502 revealed invalid font number 31502 degenerative changes invalid font number 31502 of medial, lateral invalid font number 31502 , invalid font number 31502 and patellofemoral compartments consistent with mild tricompartmental disease; osteophyte production invalid font number 31502 in the invalid font number 31502 medial and lateral invalid font number 31502 tibial invalid font number 31502 compartments; invalid font number 31502 and flattening of the medial femoral condyle. The C&P invalid font number 31502 exam findings are summarized in the chart above. invalid font number 31502 A C&P invalid font number 31502 g invalid font number 31502 eneral medical examination was performed the same day and it noted invalid font number 31502 arthritis of the right knee with invalid font number 31502 constant right knee stiffness, recurrent effusions, invalid font number 31502 mechanical invalid font number 31502 symptoms of give away, pain with twisting and rotational motions invalid font number 31502 , invalid font number 31502 and arthritis pain in the joint line regions invalid font number 31502 and medial invalid font number 31502 aspect of the knee with going up and down stairs invalid font number 31502 . This examination noted full extension of the knees and audible crepitance with movement. Strength and reflexes were normal in both upper and lower extremities. The examiner stated a ROM examination could be found in the orthopedic evaluation. invalid font number 31502
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invalid font number 31502 The Board directs attenti invalid font number 31502 on to its rating recommendation invalid font number 31502 invalid font number 31502 based on the above evidence invalid font number 31502 . invalid font number 31502 invalid font number 31502 The PEB coded the invalid font number 31502 c invalid font number 31502 hronic invalid font number 31502 r invalid font number 31502 ight invalid font number 31502 k invalid font number 31502 nee invalid font number 31502 p invalid font number 31502 ain due to invalid font number 31502 p invalid font number 31502 ost invalid font number 31502 -t invalid font number 31502 raumatic invalid font number 31502 o invalid font number 31502 steoarthritis and invalid font number 31502 p invalid font number 31502 atellofemoral invalid font number 31502 c invalid font number 31502 hondromalacia condition as 5003 invalid font number 31502 a invalid font number 31502 rthritis, degenerative (hypertrophic or osteoarthritis) rated at 10% invalid font number 31502 . The VA coded the invalid font number 31502 p invalid font number 31502 ost- invalid font number 31502 t invalid font number 31502 raumatic invalid font number 31502 d invalid font number 31502 egenerative invalid font number 31502 a invalid font number 31502 rthritis, invalid font number 31502 r invalid font number 31502 ight invalid font number 31502 k invalid font number 31502 nee, invalid font number 31502 status post invalid font number 31502 invalid font number 31502 a invalid font number 31502 rthroscopic invalid font number 31502 s invalid font number 31502 urgeries invalid font number 31502 as invalid font number 31502 5010 invalid font number 31502 a invalid font number 31502 rthritis, due to trauma, substantiated by X-ray findings invalid font number 31502 , and invalid font number 31502 rated at 10%. invalid font number 31502 The PEB and the VA chose different coding options for the knee invalid font number 31502 condition; invalid font number 31502 invalid font number 31502 however, invalid font number 31502 this did not materially invalid font number 31502 affect invalid font number 31502 the level of disability rating. invalid font number 31502 invalid font number 31502 All invalid font number 31502 X invalid font number 31502 -rays demonstrated right knee arthritis. invalid font number 31502 All exams proximate to separation invalid font number 31502 document invalid font number 31502 ed pai invalid font number 31502 n- invalid font number 31502 limited motion. invalid font number 31502 invalid font number 31502 invalid font number 31502 No exam indicated invalid font number 31502 instability invalid font number 31502 , current meniscal injury, invalid font number 31502 or invalid font number 31502 limited ROM invalid font number 31502 to a compensable level without application of §4.59 p ainful motion. VASRD §4. 71a specifies that when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate d iagnostic codes, a rating of 10% is applied under 5003 for each such major joint or group of minor joints affected by limitation of motion, as objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion . invalid font number 31502 invalid font number 31502 The Board considered the criteria for rating under invalid font number 31502 code 5260 Leg, limitation of invalid font number 31502 flexion; invalid font number 31502 invalid font number 31502 however, invalid font number 31502 the knee could not be rated higher than 10% using any exam proximate to invalid font number 31502 separation invalid font number 31502 or any alternate coding. invalid font number 31502 After due deliberation, considering all of the evide nce and mindful of VASRD §4.3 r easonable doubt , the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the c hronic r ight k nee p ain due to p ost - t raumatic o steoarthritis and p atellofemoral c hondromalacia condition. invalid font number 31502


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 chronic right knee pain due to post-traumatic osteoarthritis and patellofemoral chondromalacia 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
Chronic Right Knee Pain due to Post-Traumatic Osteoarthritis and Patellofemoral Chondromalacia 5 003 1 0%
RATING
1 0%
invalid font number 31502

The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 120613 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record




Physical Disability Board of Review


SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130018111 (PD201201198)


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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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