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AF | PDBR | CY2013 | PD-2013-02026

Original file (PD-2013-02026.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2013-02026
BRANCH OF SERVICE: Army BOARD DATE: 20150305

SEPARATION DATE: 20020924

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Personnel Administration Specialists) medically separated for right knee pain. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty; however, her physical profile authorized her to perform an alternate aerobic physical fitness test event. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition characterized as “right knee grade 3 to grade 4 chondromalacia of the patellofemoral joint and medial femoral condyle” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions, “chest pain of non-cardiac etiology” and “primary arterial hypertension on medical therapy” for PEB adjudication. The Informal PEB adjudicated “right knee pain with arthroscopic evidence of Grade III-IV chondromalacia of the medial femoral condyle and the patellofemoral joint” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION: “Upon leaving the military, I was diagnosed with Chondromalacia (R) Knee Categories III and IV. My first surgery was performed February 1999, where they said they found 26 or more bone fragments in my knee along with "kissing legions" throughout the knee. They informed me that to make the calcium grow on the bones, they had to drill 8 or more holes in the femur as well as the tibia to cause the bone to bleed. After that, I was placed on 45 days convalescent leave (bed rest with no weight bearing) and physical therapy. After maybe one year, I underwent another surgery where they removed more bone fragments. I was discharged from the military through a MEB/PEB (10%)/"Fit for duty". However, since leaving the military, I've undergone three major surgeries on my right knee; one of which was two surgeries in one, where they removed hardware from the knee, then replaced it with a Total Knee Replacement. After a year of recovery from that surgery, I've been experiencing more pain and swelling which turned out to be something called, "Heterotopic Ossification," which is supposed to be instead of bone being absorbed in my body during the healing process, it is being sent signals to grow within the muscles and/or tissues. It is a very painful situation and from what I understand, the only comfort that I can look forward to is to have another surgery in order to relieve me of the problem. The chances of it not developing again are 50% according to one source, but nothing higher from what I hear. The growth of the area was considered as “Progressive” because it was not visible on previous x-rays; however, when it was found, it had already grown to 4.5 X 1.5 CM in size. When I went to be seen by the Orthopedic Clinic in the VA, I was told by the PA attending to me, that, "It probably came from having a TBI." I have never been diagnosed with a TBI (Traumatic Brain Injury) since I've been being treated at the VA. Although, I am currently receiving treatment for migraines and I am receiving a 30% rating for the condition. I've never been quite categorized as a "TBI". I am treated for arthritis for my cervical spine, and knees.”

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 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 :

IPEB – Dated 20020607	VA* - (~3 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Right Knee Pain…	5099-5003	10%	Chondromalacia, Right Knee	5099-5024	10%	20020703
Other x 2 (Not In Scope)	Other x 17 (equals SC, NSC & deferred)
RATING: 10%	RATING: 50%

* Derived from VA Rating Decision (VA RD ) dated 20 021005 (most proximate to date of separation [ DOS ] ) .

ANALYSIS SUMMARY:

Right Knee Pain Condition. Review of the service treatment record indicated the CI developed right knee pain not associated with trauma or injury in July 2000. Ongoing pain led to arthroscopic treatment in February 2001 of right knee chondromalacia (abnormal deterioration and softening of the cartilage). A second arthroscopy was performed in January 2002 to remove a plica (redundant tissue), debride chondromalacia and remove loose bodies, but pain persisted. At the MEB exam on 21 September 2001 (12 months prior to separation) the CI reported that she used a knee brace “for stability.” The narrative summary on 7 February 2002 (8 months prior to separation) noted continued complaints of kneecap and medial knee joint pain that prevented running, kneeling and prolonged standing. Physical examination noted no knee deformity or swelling. All knee ligaments were stable and there was no evidence of a meniscal tear. X-rays showed joint narrowing. At the VA exam performed approximately 3 months prior to separation, the CI reported constant right knee pain that worsened with activity. Prolonged standing caused swelling. She used a knee brace for prolonged walking. Examination showed a normal gait. Four portal scars from the arthroscopy were well healed. There was no change in right knee range-of-motion (ROM) after repetitive motion, and painful motion was not reported. Ligament testing was normal.

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.

invalid font number 31502

Righ t Knee ROM (Degrees)	MEB ~8 Mo s . Pre-Sep	VA PE ~3 Mo s . Pre-Sep	VA Ortho ~5 Mo s. Post Sep
Flexion (140 Normal)	120	135	120
Extension (0 Normal)	0	0	0
Comment	+Tenderness, crepitus	AO	AO
§4.71a Rating	10 % *	10 % *	10 % *

invalid font number 31502 *Conceding VASRD §4.40 (functional loss) or §4.59 (painful motion) invalid font number 31502

The Board directed attention to a rating recommendation based on the above evidence. Although all exams reported non-compensable limitation of motion, a 10% determination under analogous 5003 (degenerative arthritis) or 5024 (tenosynovitis) coding was appropriate considering there was sufficient evidence of pain with use (§4.40; “functional loss”) and painful motion (§4.59). The Board considered other coding pathways to a higher rating. Application of the 5259 code (cartilage, semilunar, removal of, symptomatic) offered no advantage to the CI, since the maximum rating is 10% via that pathway. There was no evidence of recurrent subluxation or lateral instability and no history of dislocated semilunar cartilage to warrant ratings under codes 5257 (knee, other impairment of) or 5258 (dislocated semilunar cartilage). 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 pain 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 right knee pain 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131022, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150011182 (PD201302026)

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                       XXXXXXXXXXXXXXX
                                    Deputy Assistant Secretary of the Army
                                    (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2013 | PD-2013-02026

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