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AF | PDBR | CY2013 | PD-2013-02796
Original file (PD-2013-02796.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02796
BRANCH OF SERVICE: Army  BOARD DATE: 20150408
SEPARATION DATE: 20070330


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Indirect Fire Infantryman) medically separated for a left knee injury. The 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 “left tibia plateau fracture and bucket handle lateral meniscus tear” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “status post left knee injury involving left tibia plateau fracture and bucket handle lateral meniscus tear” as unfitting, rated 10%, with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “The Army only fixed a fraction of what was messed up”


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 :

IPEB – Dated 20070307
 VA* - (~15 Days Prior-Separation)
Condition
 Code Rating Condition Code Rating Exam
Status Post Left Knee Injury Involving Left Tibia Plateau Fracture and Bucket Handle Lateral Meniscus Tear 5237 10% Status Post Left Tibial Plateau Fracture w/Open
Reduction and Internal Fixation		 5299-5262 0% 20070319
Left Knee Anterior Cruciate Ligament Strain, Status Post
Meniscal Repair		 5299-5261 10% 20070319
Residual Scar of the Left Knee, Status Post Open
Reduction and Internal Fixation		 7805 0% 20070319
Left Knee Instability 5257 20% 20070319
Other x 0 (Not In Scope)
 Other x 0
RATING: 10%
 RATING: 30%
* Derived from VA Rating Decision (VA RD ) dated 200 70524 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Left Knee Injury Condition. The CI was struck in the left knee with a pugil stick in November 2006 and suffered a buckling left knee injury. X-rays and computed axial (CAT) scanning demonstrated a fracture of the lateral tibial plateau with a 1.45 centimeter fragment which was depressed approximately 8 millimeters. An examination on 13 November 2006 showed laxity of the medial collateral ligament (MCL) with no solid endpoint (MCL is on the side of the knee closest to the opposite knee and with the lateral collateral ligament [LCL], stabilizes the knee from sideways movement). The other ligaments were intact on examination (LCL and anterior cruciate ligament [ACL]). Magnetic resonance imaging (MRI) was reported to show injury to the MCL and a torn and displaced lateral meniscus. The MRI also showed possible injuries (but not tears) to the ACL and posterior cruciate ligament (PCL) (cruciate ligaments are inside the knee joint space and function to maintain the proper front-back and rotational position between the shin bone [tibia], and thigh bone [femur] during motion). At the time of surgery on 20 November 2006, examination under anesthesia demonstrated MCL instability (3+). The LCL was intact. There was some laxity of the ACL (1+) and PCL (2+), however both ligaments had an “end point” feel indicating they were intact. The displaced tibial plateau fracture was repaired with stabilizing hardware, and the torn lateral meniscus was repaired. Post-operatively, the CI was treated with non-weight bearing (8 to 12 weeks) and physical therapy (PT). The surgeon noted the CI might require ligament surgery in the future. Although the CI did reasonably well post-operatively, he was not expected to recover sufficiently within 6 to 12 months to return to infantry training and was therefore referred for a MEB. At an orthopedic appointment on 9 January 2007, 7 weeks after surgery and 3 months prior to separation, the left knee demonstrated mild swelling, trace effusion, range-of-motion (ROM) of 0 to 100 degrees (normal 0 to 140), normal muscle strength of the lower extremity, and no tenderness along the joint line or over the hardware. There was no comment regarding laxity or instability.

At the MEB exam on 12 January 2007, 2 months prior to separation, the CI reported that he had suffered a ruptured MCL and torn ACL, and had to wear a knee brace. The physical examination noted normal ROM of the left knee, presence of a scar, and a general comment of “Stable.” The final diagnosis was reported as, “Left knee tibial plateau fracture with ligament injury.” At the MEB NARSUM exam on 6 February 2007, the CI was still using crutches in accordance with the post-operative recovery plan for 8 to 12 weeks of limited weight bearing. On examination, he had had a mild knee effusion; the incision was well-healed without signs of infection; there was appropriate tenderness along the incision and joint line; and the knee ROM was 0 to 100 degrees (normal 0 to 140). Motor strength was normal (5/5) throughout. There was no specific comment regarding laxity or instability. The provider stated, “He has no evidence of complications from surgery at this point.” At a PT exam on 27 February 2007, a month prior to separation, the left knee demonstrated 115 degrees flexion (normal 140), 0 degrees extension (normal), and a 2+ Lachman test.

At the VA Compensation and Pension (C&P) exam on 19 March 2007, 2 weeks prior to separation, the examiner stated, “The claimant has been suffering from sprain left ACL.” The CI reported that he had constant pain in the left knee, could not bend his leg due to deformity of the knee, had weakness when he put weight on his leg, had stiffness (“takes a minute to get it loosened up and swelling only if standing for long period of time”), had painful motion and weakness of the implanted joint, had to walk with a slight limp and had constant pain, and that “his condition does not cause incapacitation.” The CI was not receiving any current treatment for his condition. On examination, the left knee showed “signs of weakness and tenderness.” There was no recurrent subluxation, “locking” pain, joint effusion, or crepitus. Range-of-motion was -5 to 120 degrees (normal 0 to 140), with pain starting at 120 degrees, and joint function was additionally limited after repetitive use (without additional loss of ROM). The left ACL and PCL demonstrated moderate instability. There was no lateral instability of the MCL or LCL. The medial and lateral meniscus test of the left knee was within normal limits. The surgical scar was healed and non-tender. Posture and gait were normal, and he did not require an assistive device for ambulation.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the knee with code 5257 (Other impairment, recurrent subluxation or lateral instability) at 10% (Slight), citing decreased ROM and laxity (positive Lachman test). The VA rated the knee with code 5257 at 20% (Moderate), citing instability of the ACL and PCL; and code 5299-5261 (Limitation of extension of leg) at 10%, citing painful motion. The VA also assigned a noncompensable evaluation (0%) under code 5299-5262 (Impairment of tibia and fibula), citing the history of tibial plateau fracture but with normal findings on examination. The NARSUM examination and PT evaluation on 27 February 2007 both recorded normal extension (0 degrees) with decreased flexion; the NARSUM noted joint tenderness but neither exam mentioned the presence or absence of painful motion. The VA exam described full flexion, decreased extension, painful motion, and additional loss of function with repetition.

The Board concluded that the joint pain and painful motion constituted functional loss, which was best coded as 5299-5261 at 10%. A higher rating was not supported under code 5260 (Limitation of flexion of leg) or 5261 (Limitation of extension). Returning to the history of ligament injury, the Board considered whether a separate rating was supported, under code 5257, in addition to a rating for functional loss based on painful motion. The CI incurred a significant injury to the MCL with instability demonstrated at the time of surgery. In addition, there was “possible” injury to the ACL and PCL with some laxity noted at the time of surgery. By the time of the VA C&P examination, there was no longer examination evidence of instability of the MCL consistent with healing (non-operative treatment of a MCL tear is a standard treatment which results in satisfactory healing and return to full activity in a majority of patients). Although the ACL and PCL were intact, there was evidence of residual laxity at the time of the PT examination and the VA C&P examination assessed as 2+ and moderate. The Board noted the PEB took into consideration the 1+ laxity noted in the un-injured right knee representing the normal baseline against which to compare the examination findings of the injured knee. The change from the 1+ to 2+ laxity was considered a slight change by the PEB, however, the Board instead considered the entire impairment due to instability reflected in the examinations. Although the VA examiner described the ligamentous instability (ACL and PCL) as “moderate,” the CI had normal gait, did not require a cane or other assistive device, and reported pain and weakness but not instability as his symptoms. Similarly, the post-operative orthopedic exam and the NARSUM recorded symptoms of joint pain and painful motion, but no complaints of instability. Although one examination described the physical ligamentous laxity as moderate, the Board found that the bulk of the record indicated that the actual functional disability was better characterized as “Slight” (10%). There was no pathway to a higher rating for the knee based on diagnostic codes for ankylosis; frequent episodes of “locking,” pain, and effusion into the joint (associated with the meniscus injury); or malunion of the tibia. Although the tibia was fractured, there was no evidence of malunion. Further, any rating under the tibia code (5262) would be based on impairments used for rating recommendations under the knee codes already discussed and is prohibited by VASRD §4.14 (avoidance of pyramiding). All Board members agreed an analogous rating under 5262 would not result in a higher rating, providing no benefit to the CI. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% coded 5299-5261 for painful motion and functional loss, plus a separate 10% rating for instability due to residual ligamentous laxity (coded 5257).


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. In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5261, and a rating of 10%, coded 5257, 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:

CONDITION
 VASRD CODE RATING
Status post left knee injury, with residual joint instability 5257 10%
Status post left knee injury, with residual painful motion 5299-5261 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131217, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record





        
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXXXXXXX , AR20150012774 (PD201302796)
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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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