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AF | PDBR | CY2013 | PD-2013-02773
Original file (PD-2013-02773.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02773
BRANCH OF SERVICE: Army  BOARD DATE: 20141126
SEPARATION DATE: 20071107


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this right hand dominant covered individual (CI) was an active duty E-5 (Wire Systems Installer Maintainer) medically separated for his bilateral knees. The bilateral knee condition could not be 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 for a Medical Evaluation Board (MEB). The bilateral knee condition, characterized as “knee synovitis, bilateral/chondromalacia of the patella,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded three other medically acceptable conditions (chronic neck pain, hyperlipidemia and abnormal liver function tests). The Informal PEB adjudicated “chrondromalacia” of the right knee and “tendonitis of the left knee,” rated at 0% and 0%, with likely application of AR 635-40 paragraph B-29. The remaining conditions were determined to be not unfitting and therefore not rated. The CI made no appeals and was medically separated .


CI CONTENTION: He was rated for his knees and neck. He underwent reconstructive neck surgery in 2008 and needs double knee replacement. His complete submission is at Exhibit A.


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 20071012
 VA - (4.5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chondromalacia, Right Knee 5099-5003 0% Chondromalacia, R Knee 5024 10% 20080325
Tendonitis, Left Knee 5024 0% Patellar Tendonitis, L Knee 5024 10% 20080325
Chronic Neck Pain Not Unfitting Herniated Disk, C Spine C6-7 s/p Fusion 5243 10% 20080325
Other x 2 (Not in Scope)
 Other x 3
Combined: 0%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 80411 (most proximate to date of separation)


ANALYSIS SUMMARY: The Board noted the right and left knees were examined and treated together in the record. The Board will discuss these conditions together to avoid clerical repetition and then separate them for rating considerations.

Bilateral Knee Conditions: The narrative summary (NARSUM) noted developed bilateral knee pain without reported injury in January 2007. On a clinic evaluation in May 2007, the CI had painful motion in both knees, the left greater than the right. The gait was reported as “very” antalgic. On physical examination, both knees were tender to palpation without swelling. Passive range-of-motion (ROM) of both knees was “full” with pain. No instability of either knee was present. Routine X-rays of the knees were normal. At this time, the CI was performing 3-6 mile runs, 3 times a week with his unit. On a clinic evaluation in June 2007, the CI reported pain in both knees. On physical examination more tenderness was present in the right knee. ROM of the right knee was more limited than the left secondary to pain. No instability of either knee was present. Magnetic resonance imaging (MRI) of the knees obtained on 7 June 2007, revealed a minor non-traumatic deformity of the right patella (knee cap), patellar tendinitis in the right knee and minor tendinitis in the left knee. The study showed no ligament or cartilage pathology in either knee. An orthopedic evaluation on 7 August 2007 reported no swelling or tenderness and normal motion without pain, instability or weakness of both knees. Two days later on a physical therapy evaluation, the CI reported pain and popping in both knees. The gait was described as “mildly” antalgic. ROM of both knees was normal without swelling, weakness or instability but with reported “aching.” A rheumatology evaluation to clarify the cause of the bilateral tendinitis on 4 September 2007 documented full ROM of both knees. Prominent “crepitus” was noted in the right knee and tenderness to palpation of the patella in both knees was present. No rheumatologic etiology for the knee tendinitis was uncovered.

At the 28 September 2007 MEB NARSUM evaluation, approximately 2 months prior to separation, the CI reported continued knee pain, right worse than left, and popping of the knee cap. The MEB physical exam noted the CI was to stand with obvious pain and to “limp” into the examination room. On exam the knees were both tender with the right greater than the left. No instability or swelling was present. ROM of the right knee was flexion of 100 degrees (normal 140 degrees) and extension of 0 degrees (normal 0 degrees). The left knee was flexion of 105 degrees and extension of 0 degrees, both with painful motion.

At the VA Compensation and Pension (C&P) exam performed on 25 March 2008 (approximately 5 months after separation), the CI reported continued bilateral knee pain with popping. On physical examination gait was normal. Both knees had patellar tenderness on palpation, right greater than the left, with slight swelling present in the right knee. “Moderate” crepitus (grinding) was present on the right and “moderately severe” crepitus on the left. No instability of either knee was reported. The ROM of both knees was normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated each knee condition 0% using different codes: the right knee, coded 5003 (arthritis) and left knee, coded 5024 (tendinitis) for a combined rating of 0%. The VA rated each knee 10% using code 5024 (tendinitis), for a combined rating of 20%. No higher individual rating than 10% is achievable under any of the above codes.

The Board unanimously agreed the record in evidence to reasonably support a rating of 10% IAW §4.59 for the right knee given, given the slightly reduced ROM, pain and crepitus with motion on multiple examinations. The Board was unable to determine from the record whether the left knee condition was more or less severe than the right. The Board agreed that the record in evidence supported a 10% for the left knee IAW §4.59 given the findings of decreased ROM from pain and moderately severe crepitus. The Board agreed the record in evidence did not support a rating for either knee condition under ROM codes 5260, (limitation of flexion), or 5261, (limitation of extension), and that no rating higher than 10% was supported under code 5262, (knee impairment) as the Board unanimously agreed the neither the right knee nor left knee condition rose to the level of “moderate severity” required for a 20% rating. The Board agreed that no rating could be recommended under code 5258 (cartilage dislocated) as the record recorded no “frequent episodes, of locking or effusion of either knee.” The Board noted the multiple reports by the CI of “popping” of the knees and considered a rating under code 5257, (knee instability). The Board agreed that these reports were subjective as there were no clinical findings of instability of either knee in evidence in numerous proximate examinations. The Board unanimously agreed it could recommend no rating under this code. The Board found no other appropriate codes for rating consideration or pathway to a rating higher than 10% for the right knee condition and 10% for the left knee condition. 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 knee condition and a disability rating of 10% for the left knee condition.

Contended PEB Condition. The Board’s main charge is to assess the fairness of the PEB’s determination that the neck condition was not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The CI developed neck pain in 2000 which subsided with treatment, but recurred in 2002. This was associated with intermittent numbness, tingling and pain in the right arm. An electromyography obtained on 15 February 2005 was “highly suggestive” of a right lower neck radiculopathy. By report, these symptoms resolved and no MRI of the neck was obtained. On an orthopedic evaluation on 7 August 2007, 3 months prior to separation, the CI reported no neck pain or stiffness. On physical exam no weakness or numbness of the hands or arms was reported. On the 4 September 2007 rheumatology evaluation, as reported above, the neck was described as “normal” with full ROM with no mention of pain. The CI reported no other joints other than his knees “acting up.” On an orthopedic examination on 7 September 2007, 2 months prior to separation, the CI reported no neck pain. Motor strength in the hands and arms was normal. At the MEB NARSUM evaluation the CI reported no numbness or tingling or weakness of his arms, but a low burning sensation in his lower neck. He was receiving no treatment for any neck condition at that time. On physical examination, the neck was non-tender to palpation. Mild pain on cervical flexion without spasm was noted. A mild decrease in neck flexion was recorded. The neurologic exam was normal. The C&P examination, performed 5 months after separation, reported the CI to have undergone spinal neck disc surgery with neck fusion on 14 January 2008, approximately 3 months after separation, for symptoms of increasing weakness and use of his left arm. The Board agreed that at the time of the NARSUM the CI had a mild, stable neck pain condition, which had little impact on ROM and no evidence of significant motor neuropathy. The record contained no evidence of any deterioration of the neck condition in the interval between the NARSUM evaluation and date of separation. The Board unanimously opined that the record supported that the neurological surgery, performed after separation, was the result of medical worsening of the neck condition subsequent to separation. The neck condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. It was reviewed and considered by the Board. There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended neck conditions and so no additional disability ratings are recommended.


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 condition, the Board unanimously recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a. In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a. In the matter of the contended neck condition, the Board unanimously recommends no change from the PEB determination as not unfitting and cannot recommend it for additional disability rating. 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 Chondromalacia 5024 10%
Left Knee Tendinitis 5024 10%
COMBINED (w/ BLF) 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131220, 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, AR20150007446 (PD201302773)


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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