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AF | PDBR | CY2014 | PD-2014-00135
Original file (PD-2014-00135.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2014-00135
BRANCH OF SERVICE: Army  BOARD DATE: 20150107
SEPARATION DATE: 20060406


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (11B/Infantry) medically separated for a left knee condition. This condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty, although he was authorized to perform alternate physical fitness testing. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Left knee instability, after anterior cruciate ligament (ACL)/medial collateral ligament (MCL) surgery, characterized as medically unacceptable, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated chronic pain/instability left knee as unfitting, rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “Injury was never rehabilitated to full extent.”
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 left knee condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any condition 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 20060123
 VA* - (12 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain/Instability Left Knee 5099-5003 10% Left Knee Multi-Ligament Injury 5010-5257 10% 20070331
Other x 0 (Not in Scope)
 Other x 0 (Not in Scope) 20070331
Combined: 10%
 Combined: 10%
*Derived from VA Rating Decision (VARD) dated 20070417 (most proximate to date of separation (DOS))


ANALYSIS SUMMARY:

Left Knee Condition. The treatment record documents that the CI was injured during a parachute jump on 14 December 2004. His left leg became entangled in his parachute risers causing a traumatic left knee injury. A 14 December 2004 left knee X-ray was normal. However, a 4 January 2005 left knee magnetic resonance imaging showed a bucket handle tear of the lateral (left side) meniscus (cartilage cushion in the knee) and injuries to the ACL and MCL. The ACL provides anterior stability keeping the lower leg from sliding forward of the thigh bone. The MCL provides medial [inside aspect] stability to the knee.). On 14 February 2005 the CI underwent left knee arthroscopy ( minimally invasive surgery using a joint endoscope) and repair of the lateral menisc us , ACL , and MCL . A 14 February 2005 left knee X-ray showed the expected post-surgical changes. A 27 April 2005 left knee X-ray showed a stable post-operative knee. The 28 November 2005 (4 months prior to separation) MEB narrative summary, dictated by the treating orthopedic surgeon, recounted the injury and surgical history to date. The CI did well post-operatively and complied with rehabilitation. He improved sufficiently to be released to re-enter the Ranger indoctrination program. However, the CI was unable to complete training due to worsening symptoms with the increase in activity. He developed knee laxity and associated subjective giving way. He occasionally required a cane to walk and medications for pain. The CI was unable to walk, run, or carry a rucksack without pain. Physical exam of the left knee showed minimal joint laxity with no evidence of effusion or patella (kneecap) mal-tracking. Laxity of the ACL was demonstrated by a 1+ (5 mm translation) anterior drawer and a 1A (< 5 mm translation with a firm endpoint) Lachman’s test. A pivot glide was present indicative of an ACL deficiency. Laxity of the MCL was demonstrated by a 1+ (5 mm joint space opening) valgus (inward joint displacement) test. The left knee range-of-motion (ROM) is summarized in the chart below. The diagnosis was listed as left knee recurrent instability status post ACL and MCL repair.

At the 31 March 2007 (12 months post-separation) VA Compensation and Pension (C&P) exam, accomplished by a general surgeon, the CI complained of progressively worse left knee pain, stiffness, limited motion, instability, and locking. Physical exam showed a normal gait, coordination, pulses, sensation, deep tendon reflexes, and strength (5/5). The left knee demonstrated crepitus (a grating sound or sensation) and tenderness to palpation to the medial joint line. There was no laxity, swelling, effusion, or ankylosis (joint stiffening or immobility). The left knee ROM is summarized in the chart below. The diagnosis was listed as left knee condition; with history of ACL and MCL tear repair; with residual chronic pain, decreased mobility; no instability/laxity on physical exam. The 16 April 2007 medical addendum noted that there was no loss of ROM with repetitive movement. 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.

Left Knee ROM
 (Degrees)
TMC 7 Mos. Pre-Sep TMC 6 Mos. Pre-Sep NARSUM 4 Mos. Pre-Sep VA C&P 12 Mos. Post-Sep
Flexion (140 Normal)
 FROM FROM 135 120
Extension (0 Normal)
 FROM FROM 0 0
Comment
 No painful motion No painful motion Goniometer measured ; ambulation painful --
§4.71a Rating
 0 % 0 % 10 % (4.59) (PEB 10%) 0 % (VA 10%)
IAW §4.59 (Painful motion)

The Board directed attention to its rating recommendation based on the above evidence. The 23 January 2006 PEB rated the left knee condition 10% (VASRD code 5099-5003; disability rating by analogy-degenerative arthritis) citing instability and slight constant pain IAW USAPDA pain policy. The 17 April 2007 VARD rated the left knee condition 10% (5260-5010; leg, limitation of flexion of-arthritis, due to trauma) citing pain and limited motion. The MEB exam documented minimal instability. The VA C&P exam documented no instability for rating consideration under 5257 (recurrent subluxation or instability). However, the MEB exam was accomplished by the treating orthopedic surgeon and was therefore assigned a higher probative value. The instability documented by the orthopedic surgeon supports a rating of 10% under 5257. The CI had lateral meniscus surgery, with removal of damaged tissue, and continued painful ambulation supporting a 10% rating under 5259 considering painful motion (§4.59). No route to a higher or additional rating was found. The documented ROMs did not attain a minimum rating under 5260 (limitation of flexion) or 5261 (limitation of extension). There was no ankylosis for consideration under 5256. There was no dislocated meniscus for consideration under 5258. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), 4.7 (higher of two exams), and 4.59 (painful motion), the Board recommends a disability rating of 10% for the knee condition under code 5257 and 10% under 5259 for a combined rating of 20%.


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. As discussed above, PEB reliance on the USAPDA pain policy DoDI 1332.39 for rating the left knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the left knee condition, the Board unanimously recommends a disability rating of 20%, coded 5257 and 5259, 10% each, 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
Chronic Pain/Instability Left Knee 5257 10%
Pain Status Post Repair Bucket Handle Tear of the Lateral Meniscus 5259 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20121217, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








                                   
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX , AR20150007645 (PD201400135)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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