RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01986
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20040507

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Seaman, medically separated for [bilateral] “chronic ongoing patellar instability” with a 20% (10% for each knee) disability rating.  

CI CONTENTION:  “Ongoing issues with age.”   The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20040325	VARD - 20050801	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Ongoing Patellar Instability	5099-5003
5099-5003
	10%
10%
20%	Subluxation and Tendonitis, Left Knee	5014-5257	10%	20050329	
			Subluxation and Tendonitis, Right Knee	5024-5257	10%	20050329	
Bilateral Right Greater than Left Pain	Cat II	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Ongoing Patellar Instability.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 20%, while specifically delineating 10% for the right and left knee respectively, stating that the bilateral factor was applied to reach the 20% rating.  This approach by the PEB not uncommonly reflected its judgement that the constellation of conditions was unfitting and there was no need for separate fitness adjudications. The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  However, in this instance, the PEB, in essence, rated each knee separately as delineated on the PEB document.  

According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began in January 2003 while at technical school training.  He was seen in the emergency room after his right knee dislocated while kneeling during weapons training.  He reported that his right knee dislocated two times.  Radiographic studies were obtained of his right knee on 12 February 2003 (X-rays) and 12 March 2003 (MRI).  The X-rays showed no acute osseous abnormality or fracture.  The MRI showed all ligaments and lateral collateral complexes were intact, but did show a contusion pattern consistent with transient lateral patellar dislocation.  There was no chondral defect or surgical indication.  He was initially treated with physical therapy and placed on limited duty.  

At the 26 August 2003 initial orthopedic evaluation, 8 months prior to separation, the CI complained of bilateral knee pain, right greater than left noting that since returning to his duty station he had “not really done any formal physical therapy for his knee pain.”  Physical examination showed the CI had “very significant patellar hypermobility both medially and laterally with no patellar tilt.”  The examiner further stated this did not cause the CI any significant pain and he had no specific patellar compression pain.  There was no effusion, soft tissue swelling or edema.  He had negative anterior and posterior drawer, Lachman’s and pivot shift testing.  There was no stress laxity to varus or valgus at both neutral and 30 degrees of flexion.  There was no tenderness over the patella or patellar tendon.  He had mild patellar apprehension with lateral subluxation of the patella, was neurologically intact, and had negative medial and lateral McMurray’s and negative Apley grind.  

During the 18 November 2003 MEB NARSUM examination, 6 months prior to separation, the CI reported chronic on-going patellar instability that had not fully responded to conservative management which included bracing and physical therapy.  Physical examination revealed the CI was in no acute distress or discomfort.  There was no appreciable effusion, soft tissue swelling or erythema.  Specific examination of the right knee showed excellent range of motion (ROM) with -10 degrees of extension (normal 0) and 140 degrees flexion (normal).  He had significant hypermobility both medially and laterally with normal patellar tilt and no appreciable pain with that maneuver.  He had negative anterior and posterior drawer, Lachman and pivot shift testing.  Examination of his left knee showed no laxity with varus or valgus stressing both at neutral or 30 degrees of flexion.  There was no tenderness at either patellar tendon.  He was able to squat without difficulty and had negative medial and lateral McMurray’s bilaterally.  He remained a non-surgical candidate.  

At the 29 March 2005 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported bilateral knee pain and swelling with daily flare-ups.  Physical examination revealed tenderness anterior to the knees on the right and left sides.  Right knee circumference was 37 cm and the left was 39 cm.  Drawer and McMurray tests were within normal limits on the right and left.  Upon the examination, there was slight recurrent subluxation on the right and left.  Bilateral knee flexion and extension were normal.  Pain, fatigue, weakness, lack of endurance, or incoordination did not affect ROM.  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right knee condition 20%, (delineating 10% each knee as stated above), coded 5099-5003 (degenerative arthritis).  The PEB also cited “bilateral right greater than left knee pain” as a Category II diagnosis (contributing to the unfitting condition but not separately ratable).  The VA rated the bilateral knee condition separately 10% and 10% for the left and right knees respectively, coded 5014-5257 (osteomalacia analogous to knee, other impairment of) for the left knee and 5024-5257 (tenosynovitis analogous to knee, other impairment of), citing recurrent subluxation or lateral instability.  

There was no limitation of motion or instability documented by the MEB NARSUM and C&P examinations most proximate to separation to support a rating under the codes for limitation of flexion or extension (5260, 5261), or and other knee impairment (5257).  There was no fracture, nonunion 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 was a history of cartilage, semilunar (meniscus), removal which was symptomatic (code 5259) to support a 10% rating however this was not advantageous to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right and left chronic ongoing patellar instability conditions.  

BOARD FINDINGS:  In the matter of the chronic ongoing patellar instability condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150713, 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

      In accordance with reference (a), I have reviewed the cases listed below and 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:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
	XXXXXXXXXXXXXXXXXXX  					
         Acting