RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04114
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090909

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Machinist Mate, medically separated for “left knee post-traumatic arthritis and chronic meniscus tear” and “right knee post-traumatic arthritis,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends sleep apnea which was not evaluated by the service.  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 based upon a 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 - 20090519	VARD - 20100528	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Post-Traumatic Arthritis	5099-5003	10%	Right Knee, Degenerative Arthritis, S/P ACL Repair	5010	10%	20091113	
Right Knee S/P ACL Reconstruction	Category II					
Left Knee Post-Traumatic Arthritis & Chronic Meniscus Tear…	5099-5003	10%	Left Knee, Degenerative Arthritis, S/P ACL Repair	5010	10%	20091113	
Left Knee S/P ACL Reconstruction	Category II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Left Knee Posttraumatic Arthritis.  According to service treatment records (STR), the VA Compensation & Pension (C&P) examination and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgeries in 2007 for torn anterior cruciate ligament (ACL) and medial meniscus repair and on 23 February 2009 for a meniscectomy.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB NARSUM recorded “left knee posttraumatic arthritis with acute and chronic meniscus tear, status post arthroscopy and partial medical meniscectomy” for PEB adjudication.

The MEB NARSUM examination dated 17 March 2009, less than 1 month after surgery and 6 months prior to separation, noted left knee range of motion (ROM) flexion to 100 degrees (normal 140), and extension of 0 degrees (normal 0).  The CI’s left knee was stable without joint line tenderness.

At the VA C&P examination on 13 November 2009, performed 2 months after separation, the CI reported left knee pain with weakness, stiffness, swelling, instability, giving way, locking, and fatigability.  He had flare-ups that occurred weekly, precipitating cause was unknown.  The examiner recorded that there was “additional limitation of motion and functional impairment during…flare-ups,” but did not mention the quantity.  A physical examination recorded ROM flexion to 115 degrees and normal extension.  Painful motion was present during ROM testing.  Repetition caused no change in the ROM.  The CI had joint line tenderness, but no swelling, and his left knee was stable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10% (coded 5099-5003, degenerative arthritis).  The VA rated the left knee condition 10% (coded 5010, traumatic arthritis), citing painful motion.  The recorded limitation of motion did not support 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).  The 5259 code (Cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  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).  There is therefore 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.  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 Posttraumatic Arthritis.  According to STRs, the VA C&P examination and the MEB NARSUM, the CI underwent right knee surgeries in 2002 for torn anterior cruciate ligament (ACL) and revision in 2005.  Following surgery, he was able to return to full duty until his left knee became problematic as indicated above and he was referred to an MEB.  The MEB NARSUM forwarded “right knee posttraumatic arthritis” for PEB adjudication.  At the time of the primary care clinic (PCC) appointment on 20 January 2009, the CI reported “posterior right knee pain that [was] helped significantly with medial unloader brace.”  On examination, he was noted to have mild effusion without joint line tenderness in his right knee.  Ligamentous stability tests showed that his right knee was stable and had a firm endpoint.  ROM testing documented flexion to 135 degrees (140), and normal extension.  There was no evidence of painful motion.

At the VA C&P examination on 13 November 2009, performed 2 months after separation, the CI reported right knee weakness, stiffness, swelling, instability, giving way, locking, and fatigability.  He had flare-ups that occurred weekly and were precipitated by prolonged walking, prolonged standing, prolonged sitting, squatting, or kneeling.  The examiner recorded that there was “additional limitation of motion and functional impairment during…flare-ups,” but did not mention the quantity.  Physical examination recorded ROM flexion to 115 degrees, and normal extension of 0 degrees, with painful motion.  Repetition caused no change in the ROM.  His right knee was stable and there was no swelling.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% (coded 5099-5003, degenerative arthritis).  The VA rated the right knee condition 10% (coded 5010, traumatic arthritis), citing painful motion.  The recorded limitation of motion did not support 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), or history of surgery to remove a meniscus (5259) 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).  There is therefore 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.  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.

Contended PEB Conditions:  The Navy PEB listed the “left knee status post ACL reconstruction” and “right knee status post ACL reconstruction” conditions as related diagnoses (Category 2) contributing to the disability in this case.  The Board noted that the “left knee status post ACL reconstruction” and “right knee status post ACL reconstruction” were related diagnoses to the underlying diagnoses causing the bilateral knee pain and were not separate conditions which could be separately rated (§4.14 (avoidance of pyramiding)).

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left knee status post ACL reconstruction and right knee status post ACL reconstruction, the Board unanimously agreed that it cannot recommend it for additional disability rating.  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 20141004, 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 21 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 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, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXXXXXXX
	     				  	Assistant General Counsel
						 (Manpower & Reserve Affairs)