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AF | PDBR | CY2013 | PD2013 00674
Original file (PD2013 00674.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX        CASE: PD1300674
BRANCH OF SERVICE: Army         BOARD DATE: 20140314
SEPARATION DATE: 20090921


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (19D/Cavalry Scout) medically separated for a left knee condition. The CI began having trouble with his left knee in June 2007, denying any acute trauma. The knee 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 knee condition, characterized as “chronic left knee pain from patellar mal-tracking” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded three other conditions (see rating chart below) for PEB adjudication. The Informal PEB adjudicated “chronic left knee pain” as unfitting, rated 10% with application of the VA Schedule for Rating Disabilities (VASRD). The PEB adjudicated the three other conditions listed on the chart below as not unfitting. The CI made no appeals and was medically separated.


CI CONTENTION: The CI writes: “When I was discharged from the Army the doctors could not find out what was wrong with knee. I reviewed my MRI from when I was in the Army on 03/2/2009 and the MRI was negative for any damage other that inflimation. I had an MRI done on 10/24/2009 which showed a tear on my medial meniscus. Also, a report on 1/8/2010 shows a large spur patellar enfusion that was not reported by Army doctors. I was also looked at foot pain before my discharged and I wasn't awarded anything for that injury. I just got my claim done for the VA that took years to do and I awarded 30% for flat feet. On DD Form 2808, Page 1, #35 shows that I had a normal arch in my feet. I don't belive if l had anormal arch because the VAs evaluation just over year later showed flat feet. This tells me that I went from normal feet to completely flat in just over a year. I would like a review of all evidence because I don't belive the army did a complete evaluation of my medical status upon dishcharging me from the Army.”


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 left knee condition is addressed below. The contended left foot and right knee pain conditions will also be reviewed by the Board; and, 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 (BCMR).

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws. The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. The Board likewise acknowledges the CI’s implied contention for rating of his foot condition which was determined to be not unfitting by the PEB; and, emphasizes that disability compensation may only be offered for those conditions that cut short the member’s career. The Board further acknowledges the CI’s assertion that his disability disposition was not effectively reviewed. It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations; and, redress in excess of the Board’s scope of recommendations (as noted above) must be addressed by the BCMR and/or the United States judiciary system.


 RATING COMPARISON :

Service IPEB – Dated 20090617
 VA - (1 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Left Knee Pain 5099-5003 10% Left Patellar Mal-Tracking & Chondromalacia 5260-5019 10% 20090803
Left Foot Pain Not Unfitting Left Foot Achilles Tendonitis 5284-5024 NSC 20090803
GERD Not Unfitting Gerd 7399-7346 NSC 20090804
Right Knee Pain Not Unfitting Right Patellar Mal-Tracking & Chondromalacia 5260-5019 10% 20090803
No Additional MEB/PEB Entries
 Other x 2 20090804
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 20 1 0 0120 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Chronic Left Knee Pain. The goniometric range-of-motion (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.


 Left Knee ROM
(Degrees)
Physical Therapy
~9 Mo. Pre-Sep
(20081227)
Orthopedic Clinic
~ 5 Mo. Pre-Sep
(20090416)
MEB exam
~3 Mo. Pre-Sep
(20090602 )
VA C&P exam
~1 Mo. Pre-Sep
(20090803)
VA exam
~9 Mo Post-Sep
(20100610)
Flexion (140) “ Full ROM ” “ Full ROM ” 135 126 12 0
Extension (0) “ Full ROM ” “ Full ROM ” 0 0 0
Comment Normal gait, pain at extreme of left knee flexion . No effusion, no instability, , no patellar grinding (crepitus) Normal gait, tenderness and pain Pain at rest and with motion . Slight effusion. Abnormal gait. Pain with repetitive motion.
 no instability or locking
§4.71a Rating 10% 10% 10% 10 % 10%

The service treatment records (STR) document that the CI began to experience left knee pain, without any acute injury, in June, 2007. Knee X-rays obtained on 26 August 2007, were read as normal. Orthopedic examination, dated 20 April 2009, revealed diffuse knee tenderness, including joint line tenderness, and patellar crepitus (“patellar grind”) and absence of instability, swelling, erythema or effusion (fluid in the joint). Intra-articular injections did not relieve the pain. A magnetic resonance imaging (MRI) of the left knee, dated 5 February 2009, 7 months prior to separation, revealed lateral patellar tilt and inflammation in the vicinity of the lateral left patella, without effusion (fluid in the joint) and noting also that both menisci and all ligaments were normal. On a Report of Medical Assessment, DD Form 2697, dated 1 May 2009, 4 months prior to separation, the CI reported that his “knees have got worse.” At the MEB exam, dated 2 June 2009, 3 months prior to separation, the CI reported knee pain since September, 2007. The examining physician commented that the chronic left knee pain, patellar mal-tracking, “does not meet retention standards. A permanent profile dated 2 June 2009 documents an L3 profile due to chronic left knee pain, and restricts kneeling, squatting, running, marching and jumping, and recommended MEB. On the Report of Physical examination, DD Form 2808, the MEB examiner documented (1) a positive patellar grind test, (2) “negative apprehension,” (3) “mild joint line tenderness” and (4) “puffiness inferior aspect of knee.” The examiner documented that the chronic left knee pain with patellar mal-tracking, profiled L3, was disqualifying. The MEB NARSUM, dated 2 June 2009, reported left knee pain, without antecedent trauma, which had worsened in Iraq, but during which time the CI was able to function as a driver. The NARSUM reported normal gait, mild joint line tenderness, mild edema along the inferior border of the patella and absence of ligamentous laxity, with ROM as noted in the table above.

At the VA Compensation and Pension (C&P) examination, dated 3 August 2009, a month prior to separation, the CI reported left knee pain, worse with standing, walking and driving. Examination of the left knee revealed slight effusion, tenderness along the medial patellar facet, mild patellar tracking, and an abnormal, “mild left antalgic gait” (limp). At the VA C&P general examination on the previous day, a normal gait had been documented. The VA examiner, noting the MRI result as “left patellar tilt,” recorded the diagnosis as “left patellar mal-tracking with chondromalacia.” VA records document that, on 30 December 2009, 3 months after separation, the CI underwent left knee arthroscopic synovectomy (removal of the fibrous layer which surrounds a joint). At a VA examination, dated 10 June 2010, the CI complained that “the left knee pain and swelling had gotten worse since the left knee arthroscopic surgery.” The VA physician noted tenderness only “along the medial and lateral patellar facets,” but noted the absence of effusion or instability. An MRI, dated 5 May 2010 documented residual radiologic evidence of no meniscal tear. The VARD, dated 27 August 2010, noted that examination by a VA physician noted “crepitus” (grinding), but “no evidence of instability, locking pain or subluxation,” and “continued the diagnosis of left patellar mal-tracking with chondromalacia.”

The Board directs attention to its rating recommendation based on the above evidence. The MEB physical examination noted signs which were most consistent with patellar problems rather than with internal knee disruption, such as meniscal tear. Both the MEB, 3 months prior to separation, and the VA C&P examination, a month prior to separation, diagnosed a left knee patellar condition. The PEB and the VA each chose different coding for this left knee condition, but arrived at the same rating. Neither the MEB nor the VA examinations documented limitation of motion that attained a minimum rating under the knee specific coding. The PEB rated the chronic left knee pain at 10%, analogously to VASRD code 5099-5003; namely, limitation of motion, but when any “limitation of motion...is noncompensable under appropriate diagnostic codes.” The VA similarly rated this condition at 10%, stating the same diagnosis as the PEB of “left patellar mal-tracking,” but adding chondromalacia (claimed as chronic left knee pain), “characterized by painful motion and limitation of motion.” However, the VA assigned VASRD code 5260-5019, citing that the knee condition was rated analogously to a disability “the functions affected” and “the anatomical localization” is closely related. The VARD noted that there was no evidence to support a higher rating under this code unless the ROM was more severely limited. This Board considered alternate coding under the VASRD 5200 code series. Code 5257 applies when recurrent subluxation or lateral instability exist, which had not been documented in the STRs. VASRD codes 5258 and 5259 are applicable in the setting of dislocated, or surgically removed, semilunar cartilages (menisci). The MRI, 7 months prior to separation, had noted normal menisci. As the CI’s knee condition did not suffer a limitation of motion significant enough to be compensable under either code 5260 or 5261, this Board chose to concur with the PEB, and to recommend that this condition is best rated at 10% under VASRD code 5003, for “limitation due to painful motion.” There is no route to rating higher than 10% under any applicable code and no coexistent pathology which would merit additional rating for the left knee condition under a separate code. Thus, the PEB choice of VASRD code 5099-5003 was not detrimental to arriving at the highest achievable rating IAW VASRD §4.71a. All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s coding or the 10% rating decision for the left knee condition. 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 chronic left knee pain condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the CI’s intermittent left foot pain and right knee conditions were 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.

Left foot pain condition. The Board considered whether the left foot pain condition was unfitting for continued military service. In his Report of Medical History (Form 2807) for MEB, the CI reported a “Class 3 sprain” (ankle) in 2007. Review of the STRs reveals a right foot and ankle X-ray series, dated 21 October 2007, for pain and swelling subsequent to a fall, but no clinic visits, no care for, or complaints of either left or right foot or ankle pain. Review of the CI’s problem lists in the STRs revealed no visits for foot pain. On a Report of Medical Assessment, DD Form 2697, dated 1 May 2009, 4 months prior to separation, the CI reported no foot or ankle problems. Neither the permanent profile nor the commander’s statement mentioned foot problems. The MEB examining physician documented a normal foot and ankle exam, and checked that the CI had a normal arch in his feet. Documentation of entrance physical or other previous examinations were not available for this Board to review; therefore, no determination could be made if the CI had a prior history of pes planus (flat feet). The MEB physician included a diagnosis of “left foot pain, intermittent,” noting that this met retention standards. The MEB NARSUM, the MEB proceedings and the PEB all concurred that the intermittent left foot pain met retention criteria. The CI’s VA clinic notes from 3 August 2009, one month prior to separation, document left Achilles tendon pain, subsequent to a fall in 2007, but which is not documented in the CI’s military STRs. The VA examiner added that, subsequent to this injury, there were no “flare-ups or incapacitating episodes,” and that the CI was able to “perform his usual occupation while in the service.” At the VA C&P examination, physical examination of both feet revealed no pain, edema, weakness, or tenderness, or unusual shoe wear pattern, despite a diagnosis of bilateral pes planus, and the Achilles tendons were not documented to be tender or misaligned, despite a diagnosis of left Achilles tendinitis. Board members concluded there was no evidence of a significant foot impairment prior to referral into the DES, and that the CI’s feet were not a cause or contributor for the CI’s physical limitations.

Right knee pain condition. The Board considered whether the right knee pain condition was unfitting for continued military service. STRs document that right knee X-rays were obtained on 26 August, 2007, although no right knee injury was noted, and were read as normal. A physical therapy note, dated 27 December 2008, documents right knee pain of “insidious onset” and notes that the “right knee pain has resolved.” Physical examination on the occasion noted full range-of-motion without pain or limitation in the right knee. There were no injections, no MRI was ordered and no complaints of right knee pain occurred in the orthopedic clinic notes. On 2 April 2009, the right knee was examined, and noted to have “no instability.” On a Report of Medical Assessment, DD Form 2697, dated 1 May 2009, 4 months prior to separation, and in the Report of Medical History (Form 2807), the CI reported problems in both knees. Neither the permanent profile nor the commander’s statement mentioned a right knee pain condition. On the Report of Physical Examination, DD form 2808, the MEB examining physician documented that the right knee pain met retention standards. The MEB NARSUM, the MEB proceedings and the PEB all concurred that the right knee pain condition met retention criteria. Board members concluded there was no evidence of significant right knee impairment prior to referral into the DES, and that the CI’s right knee not a cause or contributor for the CI’s physical limitations.

The left foot pain and right knee pain conditions were neither profiled nor implicated in the commander’s statement, and were not judged to fail retention standards. All were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that either the left foot pain or the right knee pain 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 left foot pain or right knee pain condition 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 chronic left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended left foot pain and right knee pain conditions, the Board unanimously recommends no change from the PEB determination as not unfitting. 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
Chronic Left Knee Pain 5099-5003 10%
Left Foot Pain Not Unfit
Right Knee Pain Not Unfit
COMBINED 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130529, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                                   
XXXXXXXXXXXXXXXXXX, DAF
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 XXXXXXXXXXXXXXXXXX , AR20140013371 (PD201300674)

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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
 ( ) DVA

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