RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03069
BRANCH OF SERVICE:  navy	SEPARATION DATE:  20060201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Electronic Technician) medically separated for “left knee patellar malalignment,” rated at 10%. 

CI CONTENTION:  The CI requested that the Board review all conditions.  The 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 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 20051207	VA* - (~15 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Patellar Malalignment	5299-5003	10%
EPTS 0% Reduction	Left Knee Status Post Surgery, with Well-Healed Scar and Osteoarthritis	5260	10%	20070502	
Left Knee Grade II-III Chonromalacia of Patella and Early Medial and Lateral Compartment Osteoarthritis	Category II					
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 2	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070613 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

Left Knee Condition.  The service treatment record (STR) documents that the CI sustained a traumatic impact to his left knee which caused a lateral patella (kneecap) dislocation.  The dislocation was reduced (procedure to restore a dislocation or fracture to the correct alignment) with assistance by another individual.  The knee was extended and the patella was manipulated until it popped back into the patellofemoral groove.  The CI failed conservative treatment which included nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, immobilization (neoprene brace), and physical therapy (PT).  He continued to experience painful, recurrent subluxations and dislocations with minimal stress.  The CI underwent a left knee diagnostic arthroscopy, examination under anesthesia, and proximal extensor mechanism realignment.  The arthroscopy revealed chondromalacia patella (pathologic changes in patellar articular cartilage).  The narrative summary (NARSUM) by orthopedic surgery, seven months before separation, recounted the history and interventions.  The CI improved after his arthroscopy, open realignment procedure, and extensive course of PT.  He continued to have moderate limitations and used a brace.  The CI complained of left knee pain on most days.  Pain was exacerbated by kneeling, squatting, crawling, biking, prolonged walking, running, and climbing activities (hills or stairs) and relieved by rest.  He was unable to crawl or kneel on his knee due to inflammation at the patellar tendon insertion.  The left knee exam revealed a well healed lateral scar.  The scar was not tender but there was some numbness on the very lateral aspect.  There was tenderness over the patella tendon insertion.  The patella tracked centrally, was slightly lax (medially and laterally), but did not sublux out of the femoral groove.  There was a mild effusion (fluid collection) and moderate retropatellar crepitus (grating sound or sensation) with range-of-motion (ROM).  The patellar grind (assesses abnormal patellar movement and painful crepitation) and valgus stress (assesses medial collateral ligament) tests were slightly positive.  The Lachman (assesses anterior cruciate ligament [ACL]) test revealed slight laxity with a good end point.  The patellar apprehension (apprehension or pain on quadriceps contraction with patella displaced), varus stress (assesses lateral collateral ligament), and pivot shift (assesses ACL) tests were negative.  The left knee ROM was flexion (0-140 normal) of -5 to 110 and extension (0) of 5 degrees.  The X-ray showed mild patellofemoral arthritis and early degenerative changes in the medial and lateral compartments.  The diagnoses listed left knee patellar malalignment, chondromalacia of the patella, and early osteoarthritis.  The subsequent orthopedic surgery evaluation reported the CI had generalized ligamentous laxity.  The left knee exam revealed a well healed midline incision.  There was tenderness around the patella and mild crepitus with ROM in the patellofemoral joint.  There was no medial joint line tenderness or effusion.  The mobility of the patella was increased, particularly in the lateral direction.  The patellar apprehension test was mildly positive.  Lachman and posterior drawer tests were negative.  The left knee ROM was flexion (0-140) of -10 to 130 and extension (0) of 10 degrees.  The CI reported that since surgery (lateral release with medial reefing), he had had no significant change in his pain symptoms, but his knee no longer dislocated.  He complained of some clicking and decreased flexion, but denied locking, instability, or further patellar dislocations.  The diagnosis listed patellofemoral pain with patellar chondromalacia status post lateral release.  

The Compensation and Pension (C&P) exam recounted the history and interventions.  The CI reported that after the surgery, his left knee no longer locked, and he denied instability.  He complained of chronic 2-8/10 pain with associated stiffness and occasional swelling.  The CI reported approximately two flares per week, that lasted about 12 hours, which he treated with an NSAID (Advil).  His daily activities were impaired in that did not run or lift and tried to avoid stair climbing.  The CI needed to change position frequently while seated and was limited to standing for less than 60 minutes.  He could perform his occupation, and unlimited walking, but missed seven days of work in the past year.  The physical exam documented a normal gait with no assistive devices.  The left knee exam revealed no redness, heat, swelling, tenderness, or instability.  The patellar inhibition test (assesses abnormal patellar movement and painful crepitation) was minimally positive and the drawer test was negative.  The left knee ROM was flexion (0-140) of 0 to 130 and extension (0) of 0 degrees.  Minimal discomfort was the limiting factor with ROM.  There was no further reduction against resistance or with repetition.  Post ROM testing there was no increase in tenderness, stiffness, redness, heat, swelling, or other abnormalities.  Muscle mass and strength was excellent.  A left knee X-ray showed minimal medial osteoarthritis.  The diagnosis listed left knee, status post medial retinacular plication and lateral release, and osteoarthritis.
The Board directed attention to its rating recommendation based on the above evidence.  The Informal Physical Evaluation Board (PEB), rated the left knee condition at 10% (VA code 5299-5003; rating by analogy-degenerative arthritis).  The PEB cited left knee patellar malalignment, Grade II-III chondromalacia of patella, and early medial and lateral compartment osteoarthritis.  The listed Category II condition (chondromalacia and early osteoarthritis) was considered to contribute to the unfitting knee condition.  The VA rating decision (VARD), citing the C&P exam 15 months after separation, rated the left knee condition at 10% (5260; leg, limitation of flexion of).  The VARD cited left knee pain, status post surgery, patellar malalignment,  chondromalacia patella, early medial and lateral compartment osteoarthritis, ROM, minimal discomfort limiting ROM, no further ROM reduction against resistance or with repetition, well-healed scar, no tenderness, no  instability, and no recurrent subluxation.  The proximate (MEB, orthopedic surgery, and C&P) exams did not demonstrate limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), dislocated meniscus (5258), symptomatic removed meniscus (5259), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  

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 for 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.  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 20140627, 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 5 May 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:

		- XXXXXXXXXXX, former USN
		- XXXXXXXXXXX, former USN
		- XXXXXXXXXXX, former USN
		- XXXXXXXXXXX, former USN
		- XXXXXXXXXXX, former USN
		- XXXXXXXXXXX, former USN