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AF | PDBR | CY2013 | PD-2013-02213
Original file (PD-2013-02213.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02213
BRANCH OF SERVICE: Army  BOARD DATE: 20140916
SEPARATION DATE: 20070924


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (88M20/Truck Driver) medically separated for right knee and right ankle conditions. The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty and was authorizes to perform an alternate event for the physical fitness test. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The right knee and right ankle pain conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “knee impairment, with instability status post ACL reconstruction and right ankle pain status post osteotomy and modified Brostrom procedure” as unfitting, rated at 10% and 0% respectively, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy for the right ankle condition. The CI made no appeals and was medically separated.


CI CONTENTION: “I am currently receiving 10% disability for my right knee. My knee locks up and pops while performing my civilian job. When that happens, I have to wear my knee brace. I am not receiving any disability for my lower back and right ankle, which was an injury I sustained while deployed to Iraq.”


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 and right ankle conditions are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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.


 RATING COMPARISON :

Service IPEB – Dated 20070801
 VA - (7 days. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Right Knee w/Instability s/p ACL Reconstruction 5257 10% Right knee, s/p ACL Repair 5260 0% 20070917
Right Ankle Pain s/p Osteotomy and Modified Brostrom Procedure 5099-5003 0% Right Ankle s/p Autologous Chondrocytes Implantation w/Reconstruction 5014 10% 20070917
Other x 0 (Not in Scope)
 Other x 3 20070917
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 20071101 ( most proximate to date of separation )





ANALYSIS SUMMARY:

Right Knee Condition. The service treatment record (STR) indicated that the CI injured his right knee on 27 March 2006 while doing physical training and taken to the emergency department and released. An examination performed 3 days after the initial injury, the examiner noted very limited range-of-motion (ROM) and tenderness over the lateral collateral ligament (LCL); outside of the knee joint), but was otherwise unremarkable. The joint was stable although testing was painful. Atrophy of the thigh and calf muscles was present. X-ray images were negative. The CI’s condition was treated conservatively with duty restrictions, physical therapy and a knee immobilizer; however he continued to experience pain, persisting “popping sensation” as well as knee giving-way and instability. A preoperative magnetic resonance imaging ( MRI ) dated   15 May 2006 , revealed damage to the anterior cruciate ligament. This was repaired with an arthroscopic surgery on 9 June 2006. He began rehabilitation for his right knee, but also had right ankle surgery on 14 July 2006 . During his convalescence period, t he CI “turned his knee” and felt “ popped and gave out ” on 20 Feb 2007 . Again, X-ray images of the right knee were normal as was an e xamination with the except ion of tenderness with compression. A permanent L3 profile was issued on 18 April 2007 for right knee and ankle pain that precluded most duties.

The commander’s statement dated 11 May 2007 stated that both the knee and ankle limited the CI’s performance of his duties. No other conditions were cited.

At the MEB examination signed on 23 May 2007, the CI reported constant throbbing, sharp and stabbing pain. He noted his “knee popp[ed] and sometimes [it] gave out on [him] on occasion.”
The MEB physical examination noted tenderness to palpation of the medial (inner) and subpatellar (below the kneecap) aspects of the right knee. There was no edema or erythema and there was a full ROM although flexion was painful. Motor strength and lower extremity reflexes were normal. A limp was noted. The MEB narrative summary (NARSUM) dated 
12 June 2007 noted the CI was status post right hamstring ACL reconstruction surgery. Even with post-operative physical therapy on his right knee, the CI anterior pain persisted predominantly with climbing stairs, getting in and out of trucks, with running and activities that resemble running. He had no complaints of locking, effusions or knee giving-way. However, the CI still relied on his brace. Gait was not recorded. The knee was stable.

At the VA Compensation and Pension (C&P) examination dated 18 September 2007, performed 7 days before separation, the CI reported his right knee flared up after prolonged walking for which he took Tylenol. Examination demonstrated moderate tenderness felt over the bilateral joint line with no laxity of the knee and no meniscal (cartilage) defects. The DeLuca criteria were negative and the neurological examination was normal . N o muscle atrophy was noted. The gait and posture were normal. The 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
Right Knee ROM
 (Degrees) 		MEB ~3 Mo. Pre-Sep VA C&P ~7 d a ys. Pre-Sep
Flexion (140 Normal) 140 140
Extension (0 Normal) - 0
Comment Muscle atrophy, no instability, painful motion N ormal gait, stable knee, no meniscal signs, pain free motion
§4.71a Rating 10 % 0 %

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a rating of 10% IAW USAPDA pain policy using code 5257 (knee, other impairment of) and the VA determined a 0% rating using code 5260 (limitation of flexion). The VA C&P examination, which was within a week of separation and of a higher probative value from a temporal perspective than the MEB examination 3 months earlier, did not demonstrate any laxity, which would warrant a 0% rating. While, the MEB examination noted moderate to severe quadriceps atrophy, there is a disparity of findings related to degree of atrophy between the MEB and VA examinations, the latter noting no atrophy. The MEB examination was performed by an orthopedic surgeon; however, the VA examination was more proximate to separation and also noted the presence of a normal gait. The Board observed that it is reasonable to assume that the CI used the leg more as rehabilitation progressed and the surgery became more remote. Even if the atrophy were moderate at separation, thought to be unlikely given the VA C&P findings, this would support no more than a 10% rating using code 5314 (Group XIV muscles-anterior thigh group) providing no benefit to the CI. Similarly, with a normal gait, stable knee, absent signs of meniscal damage and non-compensable loss of ROM, the Board found no route to a higher rating than the 10% rating adjudicated by the PEB using code 5257. 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.
Right Ankle Condition. The STR indicated the CI had rolled his ankle multiple times during his deployments in 2004 and 2005. A MRI of the ankle dated 11 May 2006 revealed damage to cartilage and bone. The CI complaint of ankle joint pain with swelling, stiffness, snapping, popping, clicking, grating and also stated his ankle felt unstable as if it gave way. Pre-surgical evaluation revealed instability. Ankle surgery was performed on 14 July 2006 to resolve the right ankle instability and to remove the cartilage lesion of the ankle. Post-operatively, he underwent physical therapy and rehabilitation. The CI was issued a permanent L3 profile dated 18 April 2007 for right knee and ankle pain with restrictions as noted above in the right knee condition section. The commander’s statement noted duty limitations from the ankle and knee. At the MEB examination dated 25 May 2007, the CI reported constant pain in the right leg to include his right ankle. The MEB physical examination of the ankle, the examiner noted no tenderness to palpation, no edema, no erythema. The examiner did note that the CI ankle had decreased dorsiflexion with pain elicited by plantar flexion, inversion and dorsiflexion. His motor strength was slightly reduced and he walked with a limp. The MEB NARSUM dated 12 June 2007 noted the CI was unable to perform basic soldier tasks. On examination, the ankle was stable and the motion slightly limited, but painful.

At the VA C&P examination, the CI reported constant pain in the right ankle. At the time of the examination, the CI was not using an ankle brace. On examination, the CI’s ROM was normal, but painful. DeLuca were negative and instability not noted. Atrophy was absent and the gait normal. The 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
Right Ankle ROM
(Degrees)		 MEB ~3 Mo. Pre-Sep VA C&P ~7 dys. Pre-Sep
Dorsiflexion (20 Normal) 20 20
Plantar Flexion (45) 40 45
Comment Stable, painful motion Painful motion; DeLuca negative
4.71a Rating ( § 4.59) 10% 10%

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating using code 5099-5003 (analogous to degenerative arthritis), for the right ankle pain IAW USAPDA policy. The VA awarded a 10% rating using code 5014 (osteomalacia) for the CI’s right ankle. The Board reviewed the application code 5014 (limitation of motion) and code 5003 (degenerative arthritis) for the right ankle condition. The VA examiner did not indicate that the CI had limitation of motion, nor was there satisfactory evidence of swelling, muscle spasm, or of painful motion. The VA examiner did noted pain on inversion during repeat testing, while the MEB examiner recorded “pain elicited by plantar flexion, inversion and dorsiflexion” of the right ankle. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right ankle condition since the both the MEB and the VA C&P examinations demonstrated painful motion.


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. As discussed above, PEB reliance on the USAPDA pain policy for rating the right knee and right ankle conditions was operant in this case and the condition was adjudicated independently of that policy by the Board. 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 right ankle condition, the Board unanimously recommends a disability rating of 10% coded 5099-5003 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 his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Right Knee 5257 10%
Right Ankle 5099-5003 10%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131102, 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, AR20150004769 (PD201302213)
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

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