RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01127
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060418

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Sonar Watch Supervisor, medically separated for “osteoarthritis, bilateral knees,” rated 10% and 10% respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contends all conditions in his application.  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 on 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 - 20060201	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Osteoarthritis, Bilateral Knees	5299-5003	10%			
		10%			
Achilles Rupture, Bilaterally	CAT III		No VA Claim in Evidence

COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Osteoarthritis, Bilateral Knees.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent bilateral arthroscopic knee surgery in 1989 for bilateral partial lateral meniscectomies and again in 1992 where a large flap of the lateral meniscus was removed and the right knee was found to be normal.  The CI did well until early 2005 when he began to complain of bilateral knee pain, stiffness and popping.  Plain film X-rays showed bilateral knee osteoarthritis.  The CI was referred to physical therapy which did not result in rehabilitation sufficient to allow for unrestricted activity.  There was no surgical indication.  The CI was not able to participate in all the activities appropriate to his rate and the MEB forwarded “osteoarthrosis, generalized” to the PEB for adjudication.  At the orthopedics clinic appointment on 27 September 2005, the CI complained of left greater than right knee pain and reported some improvement with physical therapy.  On examination, bilateral knee ROM was full, with no pain noted.  The MEB NARSUM examination on 16 November 2005, 5 months prior to separation, noted complaints of bilateral knee pain and an inability to run or climb ladders.  Physical examination showed the bilateral knees had full range of motion (ROM) noted to be guarded but painful motion was not reported.  Mild effusions as well as a patella grind bilaterally were noted, but no signs of instability in either knee.  Bilateral knee X-rays performed in conjunction with the MEB NARSUM examination showed bilateral knee osteoarthritis.  The CI did not attend a VA Compensation and Pension (C&P) evaluation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated each knee 10%, analogously coded 5299-5003 (arthritis, degenerative).  The CI has not filed a claim with the VA.  The Board noted that the CI had two operations on both knees prior to entry into the Navy; however, he served for nearly 10 years before having a recurrence of knee pain.  Although there was radiographic evidence of osteoarthritis in both knees, there was not a compensable limitation of range of motion to justify rating using VASRD code 5260 (leg, limitation of flexion of) or 5261 (leg, limitation of extension of).  Members agreed that the evidence did not support recommending separate right and left knee disability ratings.  However, a single 5003 based rating for “2 or more major joints” without ROM limitations or painful motion was warranted. There was no evidence of instability of either knee to rate using code 5257 (knee, other impairment of: recurrent subluxation or lateral instability).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral knee condition, coded 5003 (arthritis, degenerative with X-ray evidence of involvement of 2 or more major joints).  

Contended PEB Conditions:  Achilles Rupture, Bilaterally.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not implicated in the commander’s statement; however, the bilateral Achilles rupture was listed first on the Limited Duty (LIMDU) abbreviated MEB report and only the circumstances of the bilateral Achilles rupture/repair were listed on the LIMDU MEB as the “circumstances of injury/illness.”  Review of primary care and orthopedics visits proximate to separation finds that in each case the examiner stated or implied that the bilateral Achilles pain was as limiting as or more limiting than the bilateral knee pain condition stating that the CI had severe pain with running, jumping, climbing stairs or ship’s ladders, in addition he was unable to carry heavy loads or a pack and had difficulty with swimming.  After due deliberation, the Board concluded that the preponderance of the evidence with regard to the functional impairment of bilateral Achilles tendon rupture favors its recommendation as an additionally unfitting condition for disability rating.  

According to STR and the MEB NARSUM, the CI underwent surgery for a left ruptured Achilles tendon in October 2002.  After rehabilitation, his right Achilles tendon ruptured and was surgically repaired in September 2003.  All mentions in the available record of duty limitations shows that the CI was limited in his physical readiness test (PRT) and took the swim test as the aerobic component since the first Achilles tendon rupture in 2002.  The CI initially did well and was able to perform all of the duties of his rate but again presented to his primary care physician in July 2005 complaining of 2 months of constant dull bilateral ankle pain, stiffness with stretching and “tight pain” when running.  The CI was referred to orthopedics for evaluation and treatment, was given stretches to perform and placed on LIMDU.  There was no surgical indication.  The bilateral Achilles tendon pain was not able to be adequately rehabilitated to allow the CI to perform all of the duties of his rate and the MEB forwarded “nontraumatic rupture of Achilles tendon” for PEB adjudication.
The MEB NARSUM examination on 16 November 2005, 5 months prior to separation, noted complaints of pain at the distal aspect of the Achilles tendon bilaterally.  He was unable to run and climb ladders (required on board ships).  Physical examination showed tender scars over the posterior aspect of the ankles corresponding with the repairs of the Achilles tendons.  Ankle ROM is listed as 0 degrees dorsiflexion (normal 20) and 40 degrees plantar flexion (normal 45) bilaterally.  The CI also displayed difficulty ambulating on gait examination (suggesting painful motion though it was not specifically addressed).  

The Board directed attention to its rating recommendation based on the above evidence.  The Board noted that at each of the primary care and orthopedics clinic visits proximate to separation the CI complained equally of knee and ankle pain and that the ankle pain was limiting in both his Navy duties and recreational activities.  The CI had changed his exercise routine to using a recumbent bicycle due to his pain.  In addition, he had significant pain climbing ladders aboard ship.  There was not X-ray evidence of ankle arthritis or compensable limitation of range of motion using code 5270 (ankle, ankylosis of), 5271 (ankle, limited motion of) or 5272 (subastragalar or tarsal joint, ankylosis of).  There was no evidence of associated fracture to rate using code 5262 (tibia and fibula, impairment of).  The Board agreed that there was the mild limitation of motion that was not due to a joint condition, difficulty with ambulation, and complaints of pain there was sufficient evidence to apply VASRD §4.59, Painful Motion and provide a minimum compensable rating of 10% analogously coded 5099-5024 (tenosynovitis).

After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of bilateral Achilles tendon rupture favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately analogously coded 5099-5024 (tenosynovitis) and meets the VASRD §4.71a criteria for a 10% rating for each Achilles tendon with a bilateral factor.  

BOARD FINDINGS:  In the matter of the osteoarthritis, bilateral knees condition the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the contended Achilles rupture, bilaterally condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10% for each, analogously coded 5099-5024 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Osteoarthritis, bilateral knees	5003	10%	
Residuals of Achilles tendon repair, right	5099-5024	10%	
Residuals of Achilles tendon repair, left	5099-5024	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/atchs
Exhibit B.  Service Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  XXXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected to reflect the stated disposition below:

     a. XXXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List on date of discharge with a final disability rating of 30 percent (increased from 20 percent). 

     b. XXXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List on date of discharge with a final disability rating of 30 percent (increased from 10 percent). 

     c. XXXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List on date of discharge with a final disability rating of 30 percent (increased from 10 percent).   

     d. XXXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List on date of discharge with a final disability rating of 30 percent (increased from 10 percent).

     e. XXXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List on date of discharge with a final disability rating of 30 percent (increased from 10 percent).

     f. XXXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List on date of discharge with a final disability rating of 30 percent (increased from 10 percent).
 
     g. XXXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.   

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.