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AF | PDBR | CY2012 | PD2012 01594
Original file (PD2012 01594.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   CASE: PD1201594
BRANCH OF SERVICE: Army  BOARD DATE: 20130418
SEPARATION DATE: 20030924


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (62B/Construction Mechanic) medically separated for status post (s/p) anterior cruciate ligament (ACL) reconstruction of the right knee. The CI sustained two twisting injuries to his right knee, once in 2001 and again in 2002. He had knee instability that required ACL reconstruction in 2002. He completed physical therapy but was not 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 to a Medical Evaluation Board (MEB). The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated s/p ACL reconstruction right knee as unfitting, rated 20% with likely application of Department of Defense Instruction (DoDI) 1332.39. The CI made no appeals and was medically separated.


CI CONTENTION: “Conditions have worsen[ed] causing veteran to be unable to work. And my left knee has become torn and is feeling a level 10 pain due to chondromal[a]cia.”


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 s/p ACL re-construction right knee condition meets the criterion prescribed in DoDI 6040.44 for Board purview and is addressed below. Any conditions or contention 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.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation. The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which his service-incurred condition continues to burden him. It is a fact, however, 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. This role and authority is granted by Congress to the Department of Veterans Affairs.


RATING COMPARISON :

Service IPEB – Dated 20030725
 VA - (1 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Rt. Knee s/p ACL Repair 5257 20% Rt. Knee Chondromalacia, s/p ACL Repair 5257 20% 20030826
No Additional MEB/PEB Entries
 Other x 4 20030826
Combined: 20%
 Combined: 40 %
Derived from VA Rating Decision dated 20031009 (most pr oximate to date of s eparation)


ANALYSIS SUMMARY:

Right Knee Condition: The CI jumped off a 10 foot high wall and suffered a twisting injury to his right knee in June 2001. He had pain and noted a “click” with his physical exam revealing an effusion, medial joint line tenderness with a full, painless range-of-motion (ROM). He was treated with non-steroidal anti-inflammatory drugs and physical therapy (PT). In May 2002, he suffered another injury to his right knee with an unknown mechanism of injury that resulted in pain limited ROM, moderate joint effusion and bilateral joint line tenderness. He underwent magnetic resonance imaging 2 months later that revealed a lateral meniscal tear, an ACL tear and a bone bruise. Despite PT, he continued to experience persistent knee instability and locking. He underwent arthroscopic reconstruction of his ACL and debridement (trimming) of the meniscal tear. Additionally, an area of Grade III (on a scale of I-IV with IV being a full thickness defect) chondromalacia was identified on the medial femoral condyle and the anterior aspect of the weight bearing surface. He continued to have knee pain and swelling after rehabilitation.

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
 NARSUM 4 Mo s . Pre-Sep VA C&P 1 Mo nth Pre-Sep
Flexion (140 ° Normal)
 120° 120°
Extension (0 ° Normal)
 5° 10°
Comment Minimal swelling ; Lachm a n ’s 1-2+ with endpoint, N eg . posterior drawe r ; mild medial joint line tenderness; no lateral joint line tenderness ; Neg medial & lateral collateral ligament instability ; Normal sensation & strength N o r mal gait ; well-healed non- tender scar ; soft end po int on Drawer testing c om pared to left with slightly mo re give, otherwise no liga m entous instability ; No effusion or p o int tenderness
§4.71a Rating
 10 % 20 %

The narrative summary (NARSUM) performed 4 months prior to separation, noted the CI completed a full course of post-operative physical therapy; yet continued to have pain with walking, lifting, bending or other minimal exercises of his right knee. He stated that his knee pain significantly limited his ability to perform his duties and that pain was severe when running. Pertinent physical exam findings are documented in the chart above. Plain film X-rays demonstrate surgical screws in the distal femur and two fixation devices in the proximal tibia. The examiner documented that the CI’s right knee pain failed to improve; however, the CI stated that his instability had significantly improved. At the VA Compensation and Pension (C&P) exam performed a month prior to separation, the CI reported that the surgery was successful as far as stability of the knee. He had daily pain with flare-ups associated with repetitive activities. He intermittently used narcotic medications for pain control and was under the care of a physical therapist. He was prescribed a brace but typically did not use it. He had not lost any strength, but his speed was diminished and he found it difficult to navigate on uneven surfaces. Pertinent physical exam findings are documented in the chart above.

The Board directs attention to its rating recommendation based on the above evidence. The PEB applied VASRD code 5257, recurrent subluxation or lateral instability of the knee, and rated in 20% disabling citing “moderate residual laxity” consistent with verbiage found in DoDI 1332.39. The VA also applied VASRD code 5257 and rated it 20% disabling for moderate instability or recurrent subluxation. Both examinations document that the CI’s pre-surgical right knee instability was significantly improved after repair with only residual pain and swelling remaining. Additionally, both physical exams contain documentation that is most consistent with mild instability that would result in a 10% evaluation IAW code 5257. The CI did have a meniscal tear that was debrided and he did not complain of frequent episodes of locking after surgery eliminating the use of code 5259 for rating purposes. He did experience continued knee pain and swelling which was consistent with his Grade III chondromalacia as opposed to any meniscal pathology that could be rated under code 5258. Chondromalacia is coded analogously to 5014, osteomalacia, which uses 5003, degenerative arthritis, for rating purposes. Rating under 5003, states that rating will be based on, “limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved” in this case knee specific codes. The C&P exam, the exam most proximate to final separation, did document extension limited to 10 degrees which would result in a 10% disability rating under code 5261, limitation of leg extension. The Board considered separate ratings for instability and ROM impairment as established by VA FAST guidance permitting dual rating for instability (Training Letter TL 04-22) although it was not issued until 1 October 2004 (a year post-separation). Members agreed that the coding and rating scheme of 5257, slight (10%) instability, and 5261, extension limited to 10 degrees (10%), most closely approximates the true post-operative disability of the CI’s right knee and is the best clinical fit. That rating scheme would result in a combined evaluation of 20% which is the same evaluation applied by the PEB, conferring 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 s/p ACL reconstruction right knee 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. As discussed above, PEB reliance on DoDI 1332.39 for rating the right knee condition was operant in this case and the condition was adjudicated independently of that instruction by the Board. In the matter of the right knee s/p ACL reconstruction 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
Status-post ACL Reconstruction Right Knee 5257 20%
COMBINED
 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120901, w/atchs
Exhibit 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 AR20130010178 (PD201201594)

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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