RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02766
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150529
SEPARATION DATE:  20050112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-5 (Electronics Technician 2nd Class) medically separated for a bilateral knee condition.  The CI could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “bilateral retropatellar pain syndrome,” “bilateral early onset osteoarthritis of the knees” and “status post excision ganglion cyst of volar, right wrist” to the Physical Evaluation Board (PEB).  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the bilateral knee condition as Category I: unfitting, rated 10%.  The PEB determined that the referred bilateral early onset osteoarthritis of the knees was Category II: related to the Category I condition.  Finally, the PEB determined the right wrist condition to be Category III:  not separately unfitting and not contributing to the unfitting condition.  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 20040923	VA* – (~3 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral RPPS	5299-5003	10%	Arthritis Left Knee	5261	10%	20040928	
			Arthritis Right Knee	5261	0%	20040928	
Bilateral Osteoarthritis of the Knees	Category II					
S/P Excision Ganglion Cyst of the Volar, Right Wrist	Category III	Ganglion Cyst, Right Wrist	5215	10%	20040928	
		Scar, Right Wrist	7804	10%	20040928	
Other x 0 (Not In Scope)	Other x 14 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20050308 (most proximate to date of separation [DOS]).
VARD 20080813 increased DC 5261, Right Knee to 10% effective 20080220.

ANALYSIS SUMMARY:

Bilateral retropatellar pain syndrome (RPPS).  This CI has had a long history of knee pain.  Radiologic imaging showed evidence of degenerative joint disease.  His knee pain was treated with conservative measures.  In spite of all treatment efforts, the knee pain persisted and MEB was initiated.  The MEB narrative summary (NARSUM) was dated 13 August 2004.  On physical examination (PE), he was alert and in no acute distress.  Gait was normal and steady, but he had difficulty doing deep knee bend squats, due to knee pain.  PE of the knees revealed full range-of-motion (ROM), with patellofemoral crepitus bilaterally.  There was pain with patellar compression, and also some joint line tenderness medially and laterally.  There was no evidence of effusion.  Patellar apprehension test was negative. All tests for ligamentous laxity were negative.  Distal neurovascular status was intact.

The CI was medically separated from service on 12 January 2005.  Performed three months prior to separation, the CI had a VA Compensation and Pension exam.  He reported that his knee pain was constant, but did not cause incapacitation.  Due to knee pain, he had limited tolerance for prolonged walking or running.  On PE, his posture and gait were normal.  He was not using a cane or other assistive device for ambulation.  There were no signs of lowered endurance or impaired coordination.  On PE of the knees, both knees were normal in general appearance.  Right knee ROM was 0-140 degrees.  Left knee ROM was 10-140 degrees.  There was pain with motion of the left knee.  Tests for ligamentous laxity were negative bilaterally, and the neurological exam was normal.  The ROM evaluations in evidence which the Board weighed in arriving at its recommendation are summarized below.

Knee ROM
(Degrees)	MEB ~5 mos. Pre-Sep
(20040813)	VA C&P ~3½ mos. Pre-Sep
(20040928)	
	Left	Right	Left	Right	
Flexion (140 Normal)	140	140	140	140	
Extension (0 Normal)	0	0	10	0	
Comment	Full ROM, with pain on patellar compression	Full ROM, with pain on patellar compression	Limitation of extension, and painful motion	Full ROM, with no pain on motion	

The Board directed attention to its rating recommendation based on the above evidence.  The Navy PEB chose the VASRD code 5299-5003, and assigned a 10% disability rating.  The two knees were bundled together, and treated as a single unfitting condition.  The Board evaluated whether or not it was appropriate for the two knees to be “bundled” together.  The Board must determine if the PEB’s approach of combining the knees under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendation if compensable ratings for each knee are achieved IAW the VASRD.  If the Board judges that two or more separate ratings are warranted, however, it must satisfy the requirement that each “unbundled” condition was separately unfitting.  After due deliberation, the Board agreed that the evidence does not support a conclusion that each of the RPPS problems, separately, would have rendered the CI unable to perform his required military duties.  Therefore, the Board does not recommend a separate disability rating for each of the knees.  The Board determined that it is appropriate for the right knee RPPS to be bundled with the left knee RPPS, and treated as a single unfitting condition.

The Board determined that the most appropriate VASRD codes that could be applied to the bilateral knee condition fall under 5003 (arthritis, degenerative).  In considering this coding option, the Board noted there were no incapacitating exacerbations regarding the CI’s bilateral knees, thus the 20% disability level was not met.  Also, IAW VASRD §4.40 (Functional loss), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to painful motion.  There was no path to a rating higher than 10%, since there was no evidence of ligamentous instability, subluxation, or other seriously disabling joint abnormality.  After due deliberation, the Board determined that a disability rating of 10% was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic, bilateral knee pain due to RPPS.

Bilateral early onset osteoarthritis (OA) of the knees.  The Navy PEB adjudicated this condition as Category II (related to the unfitting RPPS condition).  The Board determined that the bilateral OA of the knees was indeed related to the unfitting RPPS condition, and did not constitute a separately unfitting condition for disability rating purposes.  It is appropriate for this condition to be considered Category II.  After due deliberation, considering all of the evidence and mindful of VASRD §4.14 (Avoidance of pyramiding), the Board found insufficient cause to recommend a change in the PEB adjudication of the Bilateral OA of the knees.

Other PEB Condition.  As noted above, one condition (status post excision ganglion cyst of the volar right wrist) was found by the Navy PEB to be Category III (not separately unfitting, and not contributing to the unfitting condition).  The Board’s first 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 wrist condition was investigated by the action officer, and considered by the Board.  After a thorough review of the record, the Board did not find sufficient evidence that the right wrist condition caused significant interference with satisfactory performance of military duties.  The Board determined that it was indeed Category III (not separately unfitting, and not contributing to the unfitting RPPS condition).  After due deliberation, considering all of the evidence, the Board found insufficient cause to recommend a change in the PEB adjudication for the right wrist 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 bilateral RPPS condition and IAW VASRD §4.40 and §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral OA of the knees, the Board unanimously recommends no change from the PEB determination as Category II.  In the matter of the right wrist condition, the Board unanimously recommends no change from the PEB determination as Category III.  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 20140606, 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 2 Dec 15

      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:

- XXXXXXXXXXXXXXXXXXXX former USN  
- XXXXXXXXXXXXXXXXXXXX former USN 
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN

						  XXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)