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AF | PDBR | CY2013 | PD2013 01191

Original file (PD2013 01191.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX CASE: PD1301191
BRANCH OF SERVICE: ARMY BOARD DATE: 20140114
SEPARATION DATE: 20051214

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Specialist/E-4 (63B10/Light Wheeled Vehicle Mechanic) medically separated for right anterior knee pain with early chondromalacia but no chondral defects. The onset of the CI’s right knee pain occurred in Advanced Individual Training (AIT), with running. Although he was able to pass the Army physical fitness test, he was unable to run after that time except for short bursts to avoid enemy fire while deployed. His Military Occupational Specialty (MOS) duties aggravated his pain. The condition could not be adequately rehabilitated to meet the physical requirements of his MOS or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The right knee condition, characterized as right patellar femoral pain syndrome (PFPS) was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The informal PEB adjudicated right anterior knee pain with early chondromalacia but no chondral defects as unfitting, rated 0%. The CI made no appeals and was medically separated.

CI CONTENTION: “I was given 0% disability rating for patellofemoral syndrome in my right knee and disagree because it is now a lifelong condition for which I am permanently using assistive devices. In addition it has resulted in damage to my left knee as well. A 0% rating was not justified given the long term nature of the disability, loss of mobility and overall effects to my health. The possible medical complications that could result were not taken into consideration and I am now reliant on the VA to provide the medical care and physical therapy. I use knee braces and a cane every single day and am not a candidate for surgery at this time. I am permanently physically disabled and limited in the things I can do because of my 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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. In addition, the CI was notified by the Army that his case may be eligible for review of the military disability evaluation of his mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed or eliminated during that process. The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR. The ratings for the unfitting right anterior knee pain with early chondromalacia but no chondral defects condition is addressed below. In addition, in accordance with Secretary of Defense directive for a comprehensive review of the MH diagnoses that were changed or eliminated during the Disability Evaluation System (DES) process, the CI’s case file was reviewed regarding diagnosis change or elimination, fitness determination, and rating of any unfitting MH diagnoses in accordance with the VA Schedule for Rating Disabilities (VASRD) §4.129 and §4.130. 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 20050829	VA - ~10 Mos. Post-Separation
Condition	Code	Rating	Condition	Code	Rating	Exam
Right Anterior Knee Pain w/ Early Chondromalacia but No Chondral Defects	5099-5003	0%	Patellofemoral Syndrome, Right Knee	5260	10%	20060709
No Additional MEB/PEB Entries	PTSD*	9411	70%	Multiple
	Other x 4	20060709*
Combined: 0%	Combined: 70%**

Derived from VA Rating Decision (VA RD ) dated 200 60906 (most proximate to date of separation [ DOS ] and as later amended to DOS ).

*Original VARD denied PTSD. Based on new evidence, VARD 20070326 granted PTSD @ 10%. Based on DRO review in response to Notice of Disagreement, PTSD was raised to 30% in VARD 20100914. Based on BVA Decision, it was raised again to 70% in VARD 20130625. All ratings for PTSD were effective retroactive to DOS until reduced to 50% effective 20100820.

**RD Code sheet missing from VARD 20060906. Refer to list of evidence and narrative.

ANALYSIS SUMMARY:

Right Anterior Knee Pain with Early Chondromalacia but no Chondral Defects Condition. The CI was first seen for right knee pain on 23 May 2003, 2 months after accession for a 2-week history of pain without antecedent trauma. He was treated conservatively, but again presented with right knee pain on 3 September 2003, noting that it had been present for 2 months, but again had an unremarkable history. The examination was essentially normal other than tenderness and he was treated with duty limitation and physical therapy (PT). On 18 September 2003, he noted that he had had pain since 20 July 2003 at the end of AIT. Again, no history of trauma was given and the examination unremarkable. A screening 4 days later in PT documented that he felt under stress. He was managed conservatively and was able to deploy. In-theater he was seen on 24 November 2003 and noted that he injured his knee in AIT when he fell while running and continued to run despite the pain. He was using a knee brace. He continued to be seen for his right knee while deployed and noted right knee pain on his redeployment processing form on 21 July 2004. He again was seen on multiple occasions for his right knee at his home station. He was seen in orthopedics on 2 February 2005 for a history of right knee pain for over a year. His examination, X-rays, and magnetic resonance imaging (MRI) were thought to be unremarkable and the diagnosis of PFPS was made and an MEB initiated.

The narrative summary (NARSUM) was initially dated 2 February 2005 and then a second NARSUM on 19 July 2005. The initial NARSUM noted that the right knee pain began after the CI felt a pop during a run in Basic Training. The Board noted that this is not consistent with his prior history of either no trauma or after a fall in AIT. He reported occasional swelling and instability. On examination, he had lateral joint line tenderness, but provocative testing for a meniscal tear was negative. The range-of-motion (ROM) was 5 degrees less than on the left. The knee was stable. No effusion was documented. Moderate patellofemoral crepitus was noted and a patellar compression was positive. X-rays were normal, but an MRI showed evidence of early chondromalacia. There were no chondral defects, meniscal tears, or evidence of patellar tendinopathy. Right PFPS was diagnosed. At the second NARSUM, the CI reported that the pain began in AIT while running and that he occasionally fell from the pain. He was able to run in short bursts while initially deployed, but later could not even do that. On examination, he had a bilaterally positive test for meniscal irritation (negative when examined by orthopedics), with a slight loss of active motion on the right compared to the left, but greater ROM on the right compared to the left on passive ROM. At the VA Compensation and Pension examination performed about 7 months after separation (this examination is not in evidence, but is referenced in detail in the VARD), the CI reported pain after walking 10-15 minutes or when climbing stairs. Extension to 0 degrees was painful and crepitus was present. No comment was included regarding the gait. 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.

Right Knee ROM (Degrees)	MEB ~ 5 Mo. Pre-Sep	Ortho ~ 1.5 Mo. Pre-Sep	VA C&P ~ 7 Mo. Post-Sep
Flexion (140 Normal)	135 ( 133/132/135)	130	Full
Extension (0 Normal)	0 ( 1/0/1 )	0	Full w/ Pain
Comment	No pain; passive normal. Left ROM also 135	L knee 135
§4.71a Rating	10%	10%	10%

The Board directs attention to its rating recommendation based on the above evidence. The VA awarded 10% for the subjective complaints with the objective findings and coded the knee 5260 for limitation in flexion. The PEB coded the right knee condition as 5099-5003, analogous to arthritis, and rated it at 0%. The Board considered the findings. Although the history varied considerably, the MRI showed chondromalacia. The ROM was slightly less than VA normal values on both the orthopedic and MEB examinations. Extension was painful on the VA examinations. Both painful motion and limitation of motion (with radiographic evidence of arthritis) are sufficient for a 10% disability rating. The Board considered other coding options, but found no route to rating higher than 10%. There is no specific VASRD code for PFPS. 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 coded 5099-5003.

Contended Mental Health Condition. This review complies with the Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012, and whose MH diagnoses were changed to their possible disadvantage during that process. The applicant’s case file was reviewed regarding potential diagnosis change, fitness determination, and rating of unfitting MH diagnoses in accordance with the VASRD §4.129 and §4.130. The Board reviewed the records for evidence of inappropriate changes in a diagnosis or the elimination of a potentially ratable MH condition during processing through the military DES. The Board noted no MH conditions were referred to the MEB or PEB for adjudication. Members agreed that the incidental notation of MH symptoms on the MEB physical and in the NARSUM, without correlating diagnosis or more than scant corroborating evidence, did not constitute a MH condition meeting the inclusion criteria in the Terms of Reference of the MH Review Project. Review of the records revealed only two entries documenting MH symptoms but neither noted any duty restrictions. At a 5 April 2005 follow-up for his knee, the CI denied depression and anhedonia. While depression and anxiety were noted on the MEB examination by a Family Medicine doctor, and it was also noted in the second NARSUM by the MEB physician (an orthopedic) that he had a past history of PTSD evaluated by psychiatry, this was not in evidence for review, and no MH condition was noted as failing retention standards. Neither PTSD nor any other MH condition was profiled or implicated in the commander’s statement. None were judged to fail retention standards. The evidence was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that any MH condition significantly interfered with satisfactory duty performance. While it may be conceded that the applicant experienced some symptoms of depression or anxiety during service, there is, however, no substantiated MH diagnosis in records to which the Board could attach a favorable recommendation in this case. Even if a speculative psychiatric diagnosis were conceded, it would be rendered moot by the absence of any supporting evidence that there was unfitting psychiatric impairment subject to rating. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend an addition of any MH diagnosis for disability rating.

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 5099-5003 IAW VASRD §4.71a. In the matter of the contended MH condition, the Board unanimously agrees that there was no unfitting MH diagnosis, and it cannot recommend any 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 Anterior Knee Pain	5099-5003	10%
COMBINED	10%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130826, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SFMR-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, AR20140006724 (PD201301191)

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 10% 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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

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AF | PDBR | CY2013 | PD2013 01191

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