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AF | PDBR | CY2014 | PD-2014-00375
Original file (PD-2014-00375.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-00375
BRANCH OF SERVICE: Army  BOARD DATE: 20141216
SEPARATION DATE: 20061202


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling reservist E-4 (Small Arms Repairer) medically separated for left knee chondromalacia. 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 condition, characterized as “left knee pain secondary to chondromalacia patella grade III and IV,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated this condition as unfitting, rated 0%, with implied application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “Because as soon VA evaluated the condition they granted a 10% in 2006 and now is already in 50%.”


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 20061023
 VA - (9 Months Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Grade III/IV Chondromalacia, Left Knee 5099-5003 0% Left Knee Chondromalacia of the Patella… 5257 10% 20060228
Other x 0 (Not in Scope)
 Other x 4
Rating: 10%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 60911 ( most proximate to date of separation [ DOS ] ).



ANALYSIS SUMMARY:

Left Knee Pain. The narrative summary notes the CI twisted his left knee during a sports event organized by the unit and experienced persistent pain and swelling. Examination on 4 August 2004 noted a “visible ‘pop’ at the medial edge of the patella with movement.” Magnetic resonance imaging (MRI) on 5 August 2004 noted chondomalacia of the patella with a cartilage defect (lateral aspect) and a ruptured degenerative cyst (Baker’s cyst). There were two small bony densities noted with no identifiable donor site, normal semilunar cartilage and no noted ligament injury. Arthroscopy on 3 September 2004 noted chondromalacia of the patella-femoral joint Grade III and IV, with normal semilunar cartilage and ligaments and the CI was placed on permanent profile. Physical therapy (PT) range-of-motion (ROM) on 8 August 2005 noted flexion of 110 degrees, with weakness of knee flexion. On 26 September 2006 PT ROM was flexion 32 degrees and extension lag of 15 degrees. The therapist noted an antalgic gait with “instability in the area” and irregular movement of the patella. Left knee X-rays performed on 28 February 2006 noted the two previously seen bony densities and degenerative arthritis of the knee joint.

At the MEB examination on 9 February 2006, approximately 10 months prior to separation, the CI reported left knee pain with flare-ups two to three times per week and use of a cane to walk. The MEB physical exam noted a normal gait and ROM of flexion 110 degrees and extension 0 degrees and tenderness to palpation of the kneecap.

At the VA Compensation and Pension (C&P) examination 28 February 2006, approximately 9 months prior to separation, the CI reported constant left knee pain and use of a cane. On examination there was a “good” and "steady gait” without use of any assistive device at the time. Knee ROM was flexion 129 degrees and extension lag of 5 degrees. There was a positive patellar grind test and positive signs of semilunar cartilage injury, but no evidence of lateral or anterior-posterior instability.

At a VA C&P examination on 23 May 2007, approximately 6 months after separation, the CI reported using a cane, difficulty standing or walking for long periods, pain, weakness, stiffness giving way, instability, daily locking, frequent effusions and weekly flare-ups. On examination there was an antalgic gait. Knee ROM was extension - flexion of 0 degrees – 90 degrees, decreased to 75 degrees with repetition, with positive patellar grinding and mild lateral instability noted with mild weakness graded 4/5 of knee and ankle flexion and extension. Abnormal patellar tracking was present with locking and a positive test for semilunar cartilage injury was noted. A VA C&P examination on 15 June 2007, approximately 6 months after separation primarily addressed the shoulder, also noted an antalgic gait and use of a cane due to the left knee.

Repeat MRI on 12 July 2007 at the VA noted the patella was subluxed “almost dislocated,” and the previously noted degenerative changes of the patella and knee joint and possible partial tearing of the infrapatellar tendon with a small joint effusion and otherwise normal semilunar cartilages and intact ligaments. The assessment at orthopedic evaluations on 20 December 2007 and 17 January 2008 was the CI had congenital bilateral patellar maltracking of both knees, probably exacerbated by traumatic patellar dislocation with spontaneous relocation in the initial left knee injury, but the CI was not considered a candidate for surgical realignment and a rigid knee brace was ordered.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the left knee condition 0%, coded 5099-5003 (analogous to degenerative arthritis for chondromalacia). The VA originally rated the knee condition 10%, coded 5257, (knee impairment) prior to separation citing slight instability and the post-separation VARD on 25 May 2007 increased the rating to 20%, coded 5257 for moderate instability.
The evidence in the record supports that the CI had congenital patellar instability affecting both knees, with service-aggravation of the left knee associated with significant degenerative changes of the patella femoral joint. The Board agreed that this case justifies consideration of separate ratings for instability and limitation of motion (or painful motion) as established by formal VA policy in effect at the time of separation (General Counsel Opinion of 1 July 1997 and Fast Letter 04-22 of 1 October 2004). Members were satisfied that the evidence cited above provides adequate support for rating under code 5257 for recurrent subluxation; which confers 10% for “slight” instability, 20% for “moderate,” and 30% for “severe.” The Board agreed that the evidence in record was consistent with slight instability associated with intermittent patellar subluxation as evidenced by no instability noted at the pre-separation C&P and the MEB, but instability noted at the pre-separation PT examination and abnormal patellar movement and mild lateral instability noted at the initial post separation C&P examination.

The Board next considered rating the knee for ROM. Members agreed that the evidence in record supported a 10% rating for painful, limited ROM with evidence of degenerative arthritis on imaging studies, coded 5003 (degenerative arthritis).

The Board then reviewed to see if any additional rating of the knee was applicable. Knee ROM met a compensable level for rating based on ROM alone at only one of the five evaluations noted above. However, patellar subluxation was noted by the examiner and the later C&P examination noted non-compensable flexion and extension values. The Board, therefore, concluded that the severely restricted ROM at the PT evaluation was an intermittent finding due to the patellar instability and not separately ratable. Examinations in the STR at times noted a positive signs of semilunar cartilage damage; however, the arthroscopy and MRIs did not note any semilunar cartilage damage. Thus, the Board agreed that the left knee could be dual rated as elaborated above and there was no evidence in record of any other ratable impairment. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends dual rating of the left knee condition as left knee instability, rated 10%, coded 5257; and, left knee degenerative arthritis, rated 10%, coded 5003 for a combined disability 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 may have relied on the USAPDA pain policy for rating the left knee condition 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 combined rating of 20%. 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
Left knee chondromalacia and instability 5257 10%
Left knee degenerative arthritis 5003 10%
COMBINED 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140115, 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, AR20150008504 (PD201400375)


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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