RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02341
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080508

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Submarine Nuclear Propulsion Plant Operator-Engineering Laboratory Technician, medically separated for “chondromalacia patella left knee” with a disability rating of 10%.  

CI CONTENTION:  The CI was given a higher rating for his condition by the VA.  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 - 20080117	VARD - 20090505	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patella, Left Knee	5299-5003	10%	Instability, Left Knee	5257	20%	20090115	
Left Knee Lateral Meniscal Tear	Cat II	Tenosynovitis, Left Knee 	5024-5260	10%		
		Surgical Scar, Left Knee	7804	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chondromalacia Patella, Left Knee (Subsuming Category II Condition).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI originally injured his knee in October 2004.  He was diagnosed with a meniscal tear and underwent surgical repair (arthroscopic meniscectomy) in May 2005.  He developed signs of impingement and underwent a second arthroscopic intervention in December 1006 (18 months before separation).  At that time another meniscal tear was repaired, and chondromalacia patella (damage to the cartilage under the knee cap) was also identified and surgically addressed (chondroplasty).  The operative note described an intact anterior cruciate ligament and did not mention any other ligamental pathology.  Diagnostic imaging studies (CT and MRI) likewise did not report any ligamental injuries.  There were numerous STR clinical entries which documented stability to stress testing in all planes, with none to the contrary.  One orthopedic note relayed the CI’s complaint of “some instability” (possibly referring to patellar instability) but documented objective stability to stress testing.  There were no other STR entries that documented subjective instability.  There was consistent documentation of a “slightly” antalgic gait, but no mention of the use of a brace or assistive device.  

There were numerous range of motion (ROM) measurements documented throughout the clinical course.  Other than immediate post-operative notes, flexion ranged from 125 to 140 degrees (normal 140, 45 for minimum 10%) and extension from minus 5 to 0 degrees (normal 0, minus 10 degrees for minimum 10%).  There were various STR clinical entries after the last surgery that noted a complaint of “locking,” although it was not mentioned in later entries.  With the exception of one examiner who noted “clunking” on examination (unelaborated), all examinations after the last surgery recorded negative signs of impingement.  There was no STR documentation of an effusion (other than immediately post-operative), and some entries specified the absence of effusion.  It was determined that additional surgery was not indicated; a protracted trial of conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB.  The MEB forwarded “tear of medial cartilage or meniscus of knee” and “chondromalacia of the patella” for PEB adjudication.  

The MEB NARSUM examination on 4 December 2007, 5 months before separation, documented post-operative improvement, but persistent pain “worse going down stairs and with running ... [and] ... some stiffness in his knee after prolonged sitting.”  There was no mention of locking or subjective instability.  The physical examination recorded “well healed” surgical incisions, tenderness, no effusion, stability to stress testing, negative impingement, and “full” ROM.  

At the 15 January 2009 VA Compensation and Pension (C&P) evaluation, 8 months after separation, documented the CI’s subjective complaints of “weakness, stiffness, swelling, and heat, giving way, lack of endurance, locking and fatigability.”  He complained of constant pain rated 9/10 “elicited by physical activity and twisting motions.”  The physical examination recorded a “mild left leg limp” (no brace or assistive device), a tender surgical scar, crepitus, no effusion, and no “locking pain”.  Anterior and posterior stress testing were noted to be normal, but the examiner opined that there was “moderate instability” of the medial and lateral collateral ligaments.  Measured ROM was flexion to 130 degrees and extension to 0 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10% analogously coded 5299-5003 (degenerative arthritis).  The PEB additionally adjudicated the meniscal tear as a related Category II condition (contributing to the primary unfitting condition but not separately ratable).  Although the meniscal pathology was considered in the Board’s choice of the most favorable code, it was not subject to separate rating without violation of VASRD §4.14 (avoidance of pyramiding).  The VA conferred multiple ratings for the left knee condition: 10% analogously coded 5024-5260 (tenosynovitis - limitation of flexion), citing painful motion; separate rating of instability under code 5257 (recurrent subluxation or lateral instability), citing “moderate” instability (per the C&P examiner); and, an additional 10% rating under the 7804 scar code.  

The Board Members considered a 20% rating under code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) based on the persistent complaints recorded in the STR.  Members agreed, however, that this was not sufficiently supported.  The complaints of locking appeared to subside with time and there was no objective evidence of joint impingement.  Additionally the presence of persistent effusions, a criterion not in evidence, is requisite to the rating (“and” in the rating language).  
The Board also considered separate rating of instability as conferred by the VA.  The only evidence for instability, however, was the VA examiner’s assessment.  This was counter to the findings of multiple service providers, and there was no evidence for any functional consequence of instability.  Furthermore there was no evidence for ligamental pathology by either surgical exploration or advanced imaging.  Members thus agreed that there was insufficient evidence in support of a recommendation for separate rating of instability.  There was no functional impairment linked to fitness (restricted joint mobility, interference with mandatory gear or apparel, etc.) to justify service rating of the surgical scars.  There was no minimum compensable ROM limitation, and there was no fracture with non-union or malunion or other criterion to achieve a rating higher than 10% under any alternate code.  

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 of the left knee condition.  

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.  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 20150910, 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 USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN

		
							XXXXXXXXXXXXXXXXXXX
	     				Principal Deputy, Assistant 
						Secretary of the Navy
						(Manpower and Reserve Affairs)
						Performing the Duties of the 
						Assistant Secretary of the Navy
						(Manpower and Reserve Affairs)