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AF | PDBR | CY2014 | PD-2014-01939
Original file (PD-2014-01939.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01939
BRANCH OF SERVICE: Army  BOARD DATE: 20150127
SEPARATION DATE: 20040919


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Health Care Specialist) medically separated for chronic right knee pain. The right knee condition did not improve adequately to meet the physical requirements of her Military Occupational Specialty. The CI was profiled and permitted to take the walk portion of the Army alternate physical fitness test (aerobic portion). She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The right knee was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also forwarded twelve other conditions (see rating comparison chart below) which were all judged to meet retention standards. The Informal PEB found the chronic right knee pain unfitting, and rated it 0%. The remaining conditions were all determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “Please consider all conditions.”


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 20040606
 VA* – (~2 weeks Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Right Knee Pain 5099-5003 0% Right Knee Pain 5299-5257 10% 20040902
Left Knee Pain Not Unfitting Left Knee Pain 5299-5257 10%
Hypertension Hypertension 7101 0%
Gastroesophageal Reflux Gastroesophageal Reflux 7346 10%
Hallux Valgus, with Recurrent Plantar Fasciitis Right Great Toe Bunion 5280 0%
Left Great Toe Bunion 5280-5282 0%
Bilateral Plantar Fasciitis 5284 0%
Recurrent Low Back Pain Degenerative Disc Disease 5242 20%
Migraine Headaches Migraine Headaches 8100 10%
Chronic Pelvic Pain Endometriosis 7629 0%
Status Post Hysterectomy 7617 50%
Allergic Rhinitis Rhinitis 6522 0%
Correctable Vision No VA Entry for Vision
Tendinitis, Left Shoulder Tenosynovitis, Left Shoulder 5024 10%
Left Elbow Epicondylitis Left Elbow Pain 5299-5213 0%
Myofascial Neck Pain Cervical Myofascial Strain 5237 0%
Other x 12 (Not In Scope)
 Other x 12
RATING: 0%
 RATING: 90%
* Derived from VA Rating Decision (VA RD ) dated 200 70917 (most proximate to date of separation ( DOS ) )


ANALYSIS SUMMARY:

Right Knee Pain. The CI began having right knee pain in 1989. There was no specific trauma or injury associated with the onset of right knee pain. Radiographic imaging showed degenerative joint disease, plus a right tibial stress fracture. She was kept on a series of profiles, and eventually was able to return to duty. Over the years that followed, she had multiple flare-ups of right knee pain. In October 2002, magnetic resonance imaging showed a probable “bucket-handle” tear of the right lateral meniscus (RLM). The CI underwent arthroscopic surgery, and had partial removal of the RLM. In October 2003, 11 months later, she had a second right knee surgery, with reconstruction of the anterior cruciate ligament (ACL). Post-operatively, she continued to have right knee problems. Due to the chronic, persistent nature of her right knee pain, MEB was initiated. The MEB physical examination (PE) was on 19 April 2004. There was generalized tenderness to palpation (TTP) of the right knee, maximal over the tibial plateau. There was no laxity or effusion. Patellar compression test (PCT) was positive. Right knee range-of-motion (ROM) was 0 to 118 degrees, limited by pain. In the MEB narrative summary (NARSUM), the examiner’s diagnosis of the right knee was: “Degenerative joint disease and chondromalacia, with recurrent effusions and severe symptoms associated with impairment of function, supported by x-ray evidence and documented history of recurrent incapacity.” The CI was medically separated from service on 19 September 2004. On 2 September 2004, 2 weeks prior to separation, she had a VA Compensation and Pension (C&P) exam. She reported that the right knee bothered her all the time. After sitting in one place for 20-30 minutes, she had to stretch the knee. Her posture and gait were normal. PE of the right knee revealed a well-healed surgical scar which was slightly tender. Tests for ligamentous laxity were negative. Initial right knee ROM was 0 degrees-120 degrees. Flexion decreased to 90 degrees after four repetitions. There was pain with motion, during the knee examination. The ROM evaluations, which the Board weighed in arriving at its rating recommendation, are summarized below.

Knee ROM(Degrees) MEB ~ 5 mos . Pre-Sep (20040 419 ) VA C&P ~ 2 weeks Pre -Sep (200 40902 )
Left Right Left Right
Flexion (140 Normal) 140 118 140 120
Extension (0 Normal) 0 0 0 0

The Board directed attention to its rating recommendation based on the above evidence. The Board determined that the right knee condition was essentially non-compensable based on the VASRD §4.71a codes for loss of knee motion (5260 and 5261). However; IAW diagnostic code 5259, a 10% rating is warranted when there is satisfactory evidence that a knee is symptomatic, following removal of semilunar cartilage. After due deliberation, the Board determined that a disability rating of 10% was appropriate. There was no path to a higher rating for the right knee since there was insufficient evidence of a significantly disabling knee abnormality that would justify a higher rating. Due to the history of ACL injury, the Board specifically looked for evidence of joint instability, but could find none. Also, due to the additional loss of flexion with repetitive motion, the Board considered whether a higher rating was justified IAW the legal ruling from DeLuca v. Brown (1995). The Board determined that the additional functional loss due to loss of motion on repetitive use was not sufficient to justify a higher rating. Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends a disability rating of 10% for the right knee condition. It is appropriately rated 5259, and IAW VASRD §4.71a, meets criteria for the 10% rating level.

Left knee pain. In the NARSUM, the examiner’s diagnosis of the left knee was retropatellar pain syndrome (RPPS). The PEB found the left knee RPPS not unfitting and therefore not ratable. The Board determined that, since the left knee was implicated in the Physical Profile (DA Form 3349), and in the commander’s performance statement dated 10 May 2004, it was appropriate to document the Board’s review of the left knee pain apart from the other conditions that were found not unfitting. At the April 2004 MEB PE, there was TTP in the peripatellar area of the left knee, and along the lateral joint line. PCT was positive. Left knee ROM was 0 to 140 degrees (normal). Four months later, on 23 August 2004, the CI reported pain in her left knee. There was no history of trauma to the left knee. PE revealed some TTP over the patellar tendon. There was no effusion, no instability, and ROM was full. X-ray of the left knee was normal. At the September 2004 C&P exam, PE of the left knee revealed that joint lines were nontender. Tests for ligamentous laxity were negative. Initial left knee ROM was 0-140 degrees. Flexion decreased to 130 degrees with five repetitions. As noted above, the Army PEB found the left knee RPPS not unfitting.

The Board’s main charge with respect to this condition is to assess the appropriateness of the PEB’s fitness adjudication. 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. This condition was reviewed by the action officer and considered by the Board. There was not a preponderance of evidence from the record that indicated the left knee condition significantly interfered with satisfactory duty performance. After due deliberation, and in consideration of the preponderance of the evidence, the Board found insufficient cause to recommend a change in the PEB fitness determination for the left knee condition (RPPS).

Other PEB conditions. Eleven other conditions were adjudicated by the PEB as “not unfitting and therefore not ratable.” These 11 conditions were: hypertension, gastroesophageal reflux disease (GERD) with delayed gastric emptying, hallux valgus with recurrent plantar fasciitis, low back pain (LBP), migraine headaches, chronic pelvic pain, allergic rhinitis, correctable vision, left shoulder tendinitis, left elbow epicondylitis, and myofascial neck pain.

As noted above, the Board’s main charge with respect to these other conditions is to assess the appropriateness of the PEB’s fitness adjudication. These 11 other conditions were all reviewed by the action officer and considered by the Board. The Board noted that none of these other conditions were profiled, implicated in the commander’s statement, or judged to fail retention standards. There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance. After due deliberation, and 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 these 11 other conditions. Therefore, 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. In the matter of the chronic right knee pain, the Board unanimously recommends a disability rating of 10%, coded 5259, IAW VASRD §4.71a. In the matter of the left knee RPPS, hypertension, GERD with delayed gastric emptying, hallux valgus with recurrent plantar fasciitis, LBP, migraines, pelvic pain, allergic rhinitis, correctable vision, left shoulder tendinitis, left elbow epicondylitis, and myofascial neck pain, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board therefore recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION VASRD CODE RATING
Chronic right knee pain, secondary to chondromalacia 5259 10%
COMBINED 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140413, 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, AR20150009958 (PD201401939)


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              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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