RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03751
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20030509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Systems Organizational Initial Maintenance Technician, medically separated for “chronic knee pain” with a disability rating of 10%.

CI CONTENTION:  The CI asks for consideration of all conditions. 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 - 20021231	VARD - 20040303	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Knee Pain	5299-5002-3	10%	S/P Excision of Portion of Bipartite Patella, Right Knee	5257	0%	20031103	
Excision of Bipartite Patella	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured her right knee while dancing in June 2000, which was diagnosed as a lateral patellar fracture.  Despite conservative management including a cylinder cast, a brace, and physical therapy, pain persisted and a bone scan in June 2001 demonstrated uptake in the upper two-thirds of the right patella, which could have been considered normal or chondromalacia patella versus soft tissue uptake.  X-rays in July 2001 showed mild degenerative changes of the right knee.  Computed axial tomography (CT scan) demonstrated an ununited fracture involving the lateral aspect of the patella.  The CI underwent right knee surgery in February 2002 where debridement of the pseudofibrous union between the larger and smaller portions of the bipartite patella and excision of two small ossicles in the upper lateral portion of the patella were carried out.  The CI reported significant relief of symptoms and returned to regular activities; however, the CI fell in August of 2002 and twisted her right knee, which was increasingly painful.  Magnetic resonance imaging (MRI) in September 2002 was normal.  

Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic knee pain” and “s/p excision of bipartite patella” for PEB adjudication.

The range of motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. 

Left/Right Knee ROM
(Degrees)	Ortho ~8 Mos. Pre-Sep
	MEB/Ortho                       ~7 Mos. Pre-Sep
	VA C&P ~6 Mos. Post-Sep
	
Flexion (140 Normal)	135	110 (pain increases)	130	
Extension (0 Normal)	0	0	0	
Comment	Tenderness/stable	Tenderness/painful motion/stable	Pain at the end of motion, no instability	
§4.71a Rating	10%	10%	10%	

The MEB NARSUM dated 3 October 2002 was dictated from the Orthopedics examination on 2 October 2002, which noted tenderness to palpation of the lateral femoral condyle, lateral joint line, and anterior knee.  The CI’s knee was stable and there was no effusion.  During the MEB examination (recorded on DD Forms 2807 and 2808) dated 18 October 2002, 7 months prior to separation, physical examination showed tenderness to palpation and a full ROM.  

At the 3 November 2003 VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI reported constant pain with popping sensation.  Physical examination showed no effusion; patellar position was normal; ligaments were stable; and McMurray and drawer tests were negative for a meniscal tear and instability respectively.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% (analogously coded 5299-5002-3, (arthritis, degenerative).  The VA rated the right knee condition 0% (coded 5257, (knee, other impairment of), citing normal patella position and normal X-rays. 
 
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. The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  Therefore, there was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability, although Board members noted the PEB’s use of code 5299-5002-3  likely represented VASRD analogous code 5099-5003. 

After due deliberation, and 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 “chronic knee pain” condition.

BOARD FINDINGS:  

In the matter of the “chronic knee pain” 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 20140423, 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 24 Jun 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:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC 

						XXXXXXXXXXXXXXXXXXXX
	     				  	Assistant General Counsel
						(Manpower & Reserve Affairs)