RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01728
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Boatswain Mate Seaman, medically separated for “left knee mild patellofemoral arthritis and anterior cruciate ligament insufficiency,” with a disability rating of 10%.

CI CONTENTION:  The CI contends for higher ratings given by the VA in 2009 and 2011. The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20041013	VARD - 20070419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Mild Patellofemoral Arthritis and Anterior Cruciate Ligament Insufficiency	5299-5003	10%	S/P ACL Repair Left Knee	5260	10%	20060817	
Small Bowel Obstructions	Cat III	S/P Multiple Abdominal Surgeries for Small Bowel Obstruction	7327	0%	20060817	
		S/P Recurrent Ventral Hernia Associated with Abdominal Surgeries for Small Bowel Obstruction	7339	0%	20060817	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Left Knee Mild Patellofemoral Arthritis and Anterior Cruciate Ligament Insufficiency.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgery in October 2003 for anterior cruciate ligament reconstruction.  Following surgery, orthopedic follow–up visits to September 2003 noted the CI developed patellar tendonitis.  The examinations noted tenderness to palpation of the patellar tendon with normal extension and limited flexion between 110 to 125 degrees.  Testing for instability was variable, with serial examinations noting Lachman’s of 5 millimeter or less difference in anterior translation between the left and right knees and negative anterior drawer and pivot shift tests.  The last of these orthopedic visits was the basis of the MEB NARSUM 18 September 2003 which noted continued knee pain without evidence of significant instability and recommended continued physical therapy (PT).  PT evaluations noted a normal gait with use of a knee brace.  Despite additional treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 21 May 2004, 8 months prior to separation, the CI reported arthritis in his left knee and “chronic mild knee pain due to knee surgery.”  The physical exam identified an unstable left knee and arthritis.  The MEB NARSUM examination, dated 12 August 2004, 6 months before separation, noted moderate patellofemoral crepitus and no joint line tenderness.  Tests for joint instability were positive.  Left knee X-rays showed surgical changes and mild patellar arthritis.  The MEB examiner indicated that the CI was able to perform duties such as moving furniture, but continued with knee pain and evidence of ligamentous laxity due to patellofemoral arthritis and ACL insufficiency.  

At the VA Compensation and Pension (C&P) examination in August 2006, performed 18 months after separation, the CI reported non-debilitating left knee pain and occasional swelling and he used a knee brace for prolonged walking.  He reported that he could function and perform his daily activities and the knee condition did not prevent him from working.  Physical examination noted a normal gait.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5299-5003 code (arthritis, degenerative), citing patellofemoral arthritis and ACL insufficiency.  The VA also assigned a 10% rating using the 5260 code (leg, limitation of flexion) based on the VA C&P examination 18 months after separation, citing ROM criteria.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  There was also no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  However, Board members concluded that, given the post-surgical symptoms and signs of instability and evidence of arthritis in this case, dual coding was appropriate.  There was evidence of painful motion of a single major joint with imaging evidence of arthritis supporting a 10% rating coded as 5003.  In deliberating a rating under the 5257 code (knee, other impairment of; recurrent subluxation or lateral instability), the Board considered that exam findings at all exams in record after the ACL reconstruction provided objective evidence of ACL laxity with instability symptoms and findings that were no more than mild and likewise examinations before and after separation documented a normal gait, at times with the use of a brace.  The Board agreed that this evidence supports characterizing the instability under the 5257 code as “slight”, rated 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% coded 5003, and 10% coded 5257, for a combined rating of 20% for the left knee condition.

Contended PEB Condition.  The small bowel obstructions were not implicated in the commander’s statement and were not judged to fail retention standards.   The surgeon indicated that the CI’s abdominal condition did not preclude continuation on active duty.  The small bowel obstructions were reviewed and considered by the Board.  There was no performance based evidence from the record that this condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends a disability rating as follows: 10% coded 5003 and 10% coded 5257, both IAW VASRD §4.71a for a combined rating of 20% for the left knee condition.  In the matter of the contended small bowel obstructions, 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.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Mild patellofemoral Arthritis and Anterior Cruciate Ligament Insufficiency	5003	10%	
	5257	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140421, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 9 Apr 16 ICO XXXXXXXXXXXXXXX 
	(g) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 1 Apr 16 ICO XXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (h) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 10%) effect date of discharge.
 
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.