RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02765
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20080903

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Aviation Support Equipment Technician) medically separated for a left knee condition which could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and eventually referred for a Medical Evaluation Board (MEB).  The diagnoses “status post left patellar tendon repair,” “patellofemoral dysfunction,” and “knee instability, which is likely related to failure [to] fully rehabilitate his extensor mechanism” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.    No other condition was submitted by the MEB.  The Informal PEB adjudicated “status post left patellar tendon repair one year ago” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category II (conditions that contribute to the unfitting condition).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.”  His complete submission is at Exhibit A.

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 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 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 20080609	VA* - (6 Wks. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status-Post Left Patellar Tendon Repair…	5299-5003	10%	Scar Left Knee…	7802	0%	20080718	
			Left Knee Patellofemoral Pain Syndrome Post Patellar Tendon Rupture…	5261	10%	20080718	
Knee Instability…	Cat II					
Patellofemoral Dysfunction	Cat II					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5 	
RATING:  10%	COMBINED RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20081114 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Left Knee Condition.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of a patellar tendon rupture in April 2007 followed promptly by a surgical repair.  Subsequent STR entries document an uncomplicated course with weaning from a brace and recovery of full range-of-motion (ROM).  However, the NARSUM documented persistent symptoms “which limits his ability to perform his job” after “an extensive rehabilitation program” and the maximum allowed LIMDU accommodation.  There are no STR entries documenting significant ROM limitation (after surgery), persistent effusion, locking, reported instability, or periods of incapacitation.  The NARSUM was conducted 28 April 2008 (4 months prior to separation) and documented continued pain (not elaborated) with subjective weakness and instability, use of a patellar brace (addresses mobility of patella, not overall joint instability), and inability to run or negotiate ladders.  The NARSUM physical examination recorded left quadriceps atrophy although 5/5 strength, patellar crepitus with “slight” medial tracking, the absence of effusion, and stability to stress testing in all planes (documenting Lachman’s, pivot shift, and varus/valgus stressing through 30 degrees of flexion).  The NARSUM-measured ROM was flexion to 140 degrees (normal).  

A VA Compensation and Pension (C&P) examination was conducted 18 July 2006 (6 weeks prior to separation) and documented “daily” pain rated 6/10 with subjective “weakness and stiffness,” but no mention of subjective instability or use of a brace.  The VA examiner noted that “he did have atrophy ... but this is coming back with physical therapy,” and documented the ability to do repetitive deep knee bends without loss of strength or degradation of normal ROM (but increased pain).  The VA physical examination recorded “pain in all movements ... extension mechanism is primarily affected,” a patellar grind, and the absence of swelling.  The examiner noted an anterior drawer laxity of 5 millimeters (threshold for positive), but did not comment on the firmness of the end-point or stress testing in any other plane.  The VA-measured ROM was flexion to 135 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  It is first clarified that the PEB’s Category II diagnosis of patellofemoral dysfunction is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed in the same rating.  The Category II diagnosis of instability is addressed below.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was consistent with VASRD §4.71a criteria (conceding painful motion) for the MEB ratable findings and ROM evidence.  The VA’s 10% rating under 5261 (limitation of extension) invoked painful motion, and the code choice was presumably influenced by the C&P examiner’s directed comment regarding pain primarily with extension.  There is no compensable ROM impairment or evidence for frequent effusions or locking that would support a rating higher than 10% under any applicable code; but, the Board deliberated whether additional rating for instability (code 5257) could be justified in this case.  Members agreed, however, that there was insufficient objective evidence for instability to underpin a recommendation for additional rating.  Although there was subjective instability, the only objective instability was with patellar tracking rather than with the joint itself; thus, not logically ratable under 5257.  The NARSUM examination was convincingly probative for the absence of objective joint laxity.  The C&P finding of mild anterior laxity by the drawer sign was unelaborated, and no other planes were tested. Furthermore an isolated patellar tendon injury would not be clinically associated with any ligamentous instability, and it is noted that the VA rater did not find grounds for additional rating of instability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left knee condition.

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 left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 8 Jan 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN   
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN  
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 

				XXXXXXXXXXXXXXX
	     			Assistant General Counsel
				(Manpower & Reserve Affairs)