RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03301
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20040602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Water Well Drilling Technician) medically separated for “bilateral knee instability and pain,” rated at 10%. 

CI CONTENTION:   “Please consider all conditions.”

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 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 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 20040209	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Instability and Pain (presumed Left)	

5299-5003
	
10%
	S/P Left Knee High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction w/ Arthritic Changes	5260-5003	10%	20040816	
Bilateral Knee Instability and Pain (presumed Right)	5299-5003	10%	S/P Right Knee Anterior Cruciate Ligament Reconstruction	5260-5003	10%	20040816	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 9 	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20041019 (most proximate to date of separation [DOS]).  	

ANALYSIS SUMMARY:  The Board notes that the PEB adjudicated “bilateral knee instability and pain”; however, provided individual 10% ratings for each knee, coded 5299-5003, for combined 20% rating, with the bilateral factor applied.  Therefore, the Board deliberated rating recommendations below separately for the unfitting left knee and the unfitting right knee at separation.

Left Knee Condition.  The narrative summary (NARSUM) noted that the CI reported left knee pain and giving way in 2001 and magnetic resonance imaging (MRI) 9 August 2001 showed a torn anterior cruciate ligament (ACL), medial meniscal tears (MMT), and chondromalacia of the medial femoral condyle (MFC).  Three surgical procedures were performed on the left knee - arthroscopy 3 October 2001, ACL repair 20 November 2001, and repair of an articular cartilage defect of the MFC 23 September 2002.  Following the last surgical procedure the CI continued to report medial left knee pain, without locking and exams noted medial joint line tenderness (MJLT) without instability.  Serial X-rays of the left knee and leg after surgery noted post-surgical changes with hardware in place, good alignment of the left lower extremity, and degenerative joint disease (DJD) of the knee.  At an orthopedic follow-up visit 6 January 2003, 5 months before separation the CI reported no pain with weight bearing, but pain with flexion of the knee.  

At the MEB exam 18 November 2003, 7 months before separation, the CI reported following the multiple surgeries there was no further giving way of the left knee and he was able to walk without pain, but the knee pain was aggravated by weight bearing activities.  The MEB physical exam noted left knee range-of-motion (ROM) of extension-flexion 0 to 135 degrees (normal 0 to 140), and “mild” MJLT, without effusion or evidence of instability.  Left knee X-rays showed post-operative changes and mild arthritic changes.

At the VA Compensation and Pension (C&P) exam 16 August 2004, 2 months after separation, the CI reported knee pain aggravated by ROM and weight bearing activities, and relieved by medication and rest.  The exam noted a well healed scar of the left knee that did not cause any limitation of function.  Knee ROM was extension-flexion of 0 to 150 degrees, with pain and there was no evidence of instability or symptoms due to meniscal (semi-lunar cartilage) injury.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and the VA both rated the left knee condition 10%.  The PEB coded the knee condition 5299-5003 (analogous to degenerative arthritis) and the VA coded it 5260-5003 (degenerative arthritis with limited leg flexion).  The Board agreed that the evidence in record supports a 10% rating for the left knee condition coded either according to 5003 criteria for imaging evidence of arthritis with limited motion of a major joint, or coded as 5299-5260 for painful motion IAW VASRD §4.59 (Painful motion).  The Board reviewed to see if a higher rating was supported for the left knee, but there was no evidence of limited ROM that met a 10% rating based on ROM alone, instability, symptomatic meniscal injury, or ankylosis.  The Board next considered whether coding analogously to 5255 (impairment of the femur) or 5262 (impairment of the tibia/fibula) provided a higher rating.  Both codes provide a 10% rating for ‘mild’ and 20% for ‘moderate’ knee disability.  However, the CI reported no pain with walking, but increased knee pain with more strenuous weight bearing activities.  Member consensus was that the evidence was consistent with characterizing the left knee disability as mild and not moderate, and therefore, neither code would provide a ratings benefit versus coding as 5003 or 5260.  The Board discussion also noted that according to 5003 rating criteria the two knee joints could be rated as a bilateral condition based on imaging evidence of degenerative arthritis in two major joints.  However, this coding approach results in a 10% combined rating for the two knees and no higher as there was no evidence in record of occasional incapacitating episodes as specified for the 20% rating, and therefore, this rating approach was abandoned.  The Board thus determined that the evidence supports a 10% rating for the left knee condition and no higher.  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

Right Knee Condition.  The narrative summary (NARSUM) noted that the CI underwent multiple surgical procedures to the left knee and following the last surgery he also began to report right knee pain and instability.  Right Knee MRI 23 October 2002 showed a torn ACL and MMT, with chondromalacia of the MFC.  Surgery was performed 14 August 2003 for repair of the right knee ACL and MMT.  Following the surgery, notes in the service treatment record indicated the right knee was stable, but the CI continued to report knee pain with activity.

At the MEB exam 18 November 2003, 7 months before separation, the CI reported he was able to walk without pain, but knee pain was aggravated by weight bearing activities.  The MEB physical exam noted right knee range-of-motion (ROM) of extension-flexion 0 to 125 degrees (normal 0 to 140), without MJLT, effusion, or evidence of instability.  Right knee X-rays showed post-operative changes and mild arthritic changes.

At the VA Compensation and Pension (C&P) exam 16 August 2004, 2 months after separation, the CI reported knee pain aggravated by ROM and weight bearing activities, and relieved by medication and rest.  The exam noted a well healed scar that did not cause any limitation of function.  Knee ROM was extension-flexion of 0 to 150 degrees, with pain and crepitus, but without instability or symptoms due to meniscal injury.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and the VA both rated the right knee condition 10%.  The PEB coded the knee condition 5299-5003 (analogous to degenerative arthritis) and the VA coded it 5260-5003 (degenerative arthritis with limited leg flexion).  By the same rational as elaborated above for the left knee condition, the Board agreed that the evidence in record supports a 10% rating for the right knee condition and no higher.  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 right knee condition

BOARD FINDINGS: In the matters of the left and right knee conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  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 20140702, 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 19 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:

		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN