RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02355
BRANCH OF SERVICE:  navy 	SEPARATION DATE:  20060608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, aircraft intermediate maintenance, medically separated for “anterior cruciate ligament [ACL] insufficiency” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that his left knee was underrated and that his diabetes should have been rated.  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 - 20060227	VARD - 20060609	
Condition	Code	Rating	Condition	Code	Rating	Exam	
[Left] ACL Insufficiency	5299-5003	10%	Postoperative Residuals of Injury, Left Knee	5260	0%	20060425	
Diabetes Mellitus Type II	Cat III	Diabetes Mellitus (Type II)	7913	20%	20060425	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Anterior Cruciate Ligament Insufficiency Status Post Reconstruction.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgery in February 2005 for ACL insufficiency.  

The 26 January 2006 orthopedic MEB NARSUM, 5 months prior to separation, noted complaints of left knee pain with movement.  The CI also reported that his left knee felt loose and lame, which was worse with standing activities.  On physical examination the left knee had extension of -4 degrees (normal 0) and flexion of 120 degrees (normal 140).  “He was stable to Lachman (for ACL laxity) at a 1+ Lachman and stable to varus, valgus and posterior drawer.”  There was patellofemoral crepitus and pain.  Provocative maneuvers to elicit instability or meniscal pathology were negative.  

During the 31 January 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported increased pain in the left leg and numbness.  Physical examination showed full range of motion (ROM).  There was crepitus, tenderness to palpation and continued left knee pain.  

At the 25 April 2006 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported left knee stiffness, swelling, fatigue, and instability with constant 5 of 10 pain.  The CI denied functional impairment.  Physical examination showed normal ROM (extension of 0 degrees and flexion of 140 degrees).  Pain, fatigue, weakness, lack of endurance or incoordination did not cause additional functional loss after repetitive use.  Ligamentous stability tests and meniscal pathology tests were within normal limits.  

At the 20 December 2006 physical medicine examination, 6 months after separation, the CI reported left knee pain.  ROM testing showed extension of 0 degrees and flexion of 110 degrees.  There was minimal crepitus with knee flexion.  There was no pitting edema, effusion or tenderness.  Tests to elicit ligamentous instability were positive (Lachman’s and anterior drawer tests showed anterior translation at the left tibia, and valgus and varus test was positive.  Tests for meniscal pathology were negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5299-5003 (analogous to degenerative arthritis).  The VA originally rated the left knee condition 0%, coded 5260 (limitation of flexion), citing  “evidence does not show painful motion, limitation of motion due to pain, slight recurrent subluxation or instability, flexion limited to 45 degrees, or extension limited to 10 degrees.”  However, the VA increased the rating to 10% in September 2007 (15 months after separation), coded 5257 (knee, other impairment of with recurrent subluxation or lateral instability), based on the C&P examination 6 months after separation.  

The panel considered whether the PEB found the left knee unfitting because of pain or instability.  Members agreed that the selection of the analogous 5003 code was indicative of unfitting knee pain, but the specification of ACL insufficiency was indicative of unfitting knee instability.  Therefore, the panel agreed that both pain and instability were potentially eligible for rating.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) and there was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no history or evidence 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 those codes.  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).  However, the MEB examination showed a 1+ Lachman, for evidence of slight ACL laxity, and the C&P examination 6 months after separation showed mild subluxation or lateral instability, supporting a 10% rating under the 5257 code (knee, other impairment).  There was not sufficient evidence for dual rating of the knee, and there was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.  

Contended PEB Condition:  Diabetes Mellitus Type II.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was noted on the 25 August 2005 limited duty report (LIMDU), was judged to interfere with reasonable performance of assigned duties by the NARSUM, and was forwarded on the MEB cover sheet.  No specific conditions were specifically implicated in the non-medical assessment (NMA/commander’s statement).  The 7 February 2006 NARSUM addendum, 4 months prior to separation, documented that the CI was on oral medications only (no insulin injections).  The CI’s hemoglobin A1C had improved from 12.2 (normal range 4.1-6.5) on 11 April 2005, to 8.8 on 10 January 2006.  The physician’s diagnosis stated “diabetes which is not optimally controlled” and the physician’s plan included increasing oral medications.  

At the 25 April 2006 C&P evaluation, 2 months before separation, the CI reported diabetic ketoacidosis with one hospitalization during the past year, without problems with hypoglycemia.  He noted progressive lower extremity loss of strength with tingling and numbness, hypertension (on medication), and urinating 10 times per day.  Treatment of diabetes was with two oral medications.  Physical examination showed a normal neurovascular examination with protein and glucose in the urine assessed as “glycosuria consistent with type II diabetes.”  

The panel adjudged that the diabetes mellitus Type II condition was not controlled at the time of separation and that the preponderance of evidence indicated that it interfered with required duty and was unfitting.  Of note, post-separation VA treatment records (14 November 2006), 5 months after separation, documented that the CI was started on insulin injections.  

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the diabetes mellitus (Type II) condition 20%, coded 7913 (diabetes mellitus) based on the C&P examination 2 months before separation, citing diet restriction and oral medications.  

The panel agreed the requirement for an oral hypoglycemic agent and restricted diet justified a 20% rating.  Because there was no evidence of insulin use and medically-prescribed regulation of activities, the next higher 40% rating was not justified.  

After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of the diabetes mellitus Type II condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 7913 and meets the VASRD §4.119 criteria for a 20% rating.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended diabetes condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 20%, coded 7913 IAW VASRD §4.119.  There are no other conditions within the panel’s scope of review for consideration.  The panel 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	
[Left] ACL Insufficiency	5299-5003	10%	
Diabetes Mellitus Type II	7913	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150614, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 22 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(m) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(n) PDBR ltr dtd 21 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(o) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX

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

     a. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

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

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     h. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     i. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     j. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     k. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     l. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     m. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     n. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXXX
	Acting