RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02362
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20030203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E6, Maintenance Technician, medically separated for “bilateral knee degenerative joint disease (DJD) and symptomatic arthritis” with a disability rating of 10%.  

CI CONTENTION:  “My service on submarines strongly contributed to the deterioration in both of my knees…”  The CI’s 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 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 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 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 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 - 20021003	VARD   NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee DJD and Symptomatic Arthritis	5299-5003	10%	No VA Rating	20021205	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Knee Degenerative Joint Disease and Symptomatic Arthritis.  The PEB combined the right and left knee conditions under a single service disability rating, coded analogously to 5003 and rated 10%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that 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 the PEB’s approach of 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.  The evidence for the right and left knee conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent surgery on his right knee initially in March 1988 to remove several internal loose bodies.  He apparently recovered fully and did well until 1997 when he noted bilateral knee pain with physical training.  He was noted to be overweight.  Both knees showed signs of meniscal (internal cartilage cushions) impingement.  He was treated with medications and low impact activities were recommended.  He continued to have problems though and was determined to have a right medial meniscal tear (MMT) which was repaired on 10 March 1998.  Degeneration of the cartilage lining the joint was also noted.  This improved his symptoms temporarily, but then he had recurrent symptoms in late 2000.  An MRI of the right knee on 18 December 2000 showed the cartilage degeneration and a recurrent MMT.  He was placed on LIMDU and had repeat surgery on 12 July 2001.  He also underwent an HTO (high tibial osteotomy), a surgical procedure to correct a varus deformity (bow-legged).  He recovered well, but also had left knee pain.  An MRI on 4 December 2001 showed a MMT of the left knee as well as a cartilage defect similar to the right side.  Surgery was accomplished on the left knee on 11 February 2002.  His recovery was complicated by an infection near the left hip (donor site for the bone graft).  Following surgery for each knee, the CI was placed on LIMDU and sent to physical therapy for knee rehabilitation.  

In orthopedics on 18 June 2002, the CI reported that the right knee had minimal pain and that the left was improving.  Both knees were stable with minimal tenderness.  There was no effusion (fluid).  Extension was normal bilaterally at 0 degrees and flexion limited to 125 degrees on the right and 120 degrees on the left.  X-rays studies showed that both were healing as expected.  However, significant duty limiting symptoms persisted and the CI was referred for an MEB.  It was also noted that the CI now weighed 310 pounds, an increase of 117 pounds since accession.  

The NARSUM evaluation, dated 1 July 2002 indicated that the CI was not physically qualified for submarines or shipboard duty and could not be deployed, climb stairs or ladders, or participate in physical readiness training.  The orthopedic examination from 18 June 2002 was cited under the examination.  It was thought that his prognosis for continued military service was poor, but fair to good for civilian life.  

At the VA Compensation and Pension (C&P) evaluation, performed on 5 December 2002, 2 months before separation, the CI reported his pain was worse with prolonged standing, walking, or going up and down stairs.  They did not lock up or give out.  The physical examination showed non-tender scars over both knees.  His weight was 317 pounds.  The posture and gait were normal.  He could toe and heel walk without difficulty.  Extension was normal, but flexion limited to 130 on the right and 110 on the left.  Both were painful at the limit of motion, more on the left than the right.  

The range of motion (ROM) evaluations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Knee ROM
(Degrees)	PT ~9 Mos. Pre-Sep	MEB ~8 Mos. Pre-Sep	VA C&P ~2 Mos. Pre-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	125	130	120	125	110	130	
Extension (0 Normal)	0	0	0	0	0	0	
Comment	Stable, no effusion, tender	Stable, no effusion, non-tender	Slight effusion, mild tenderness, stable	No effusion, stable, non-tender	Painful motion	Painful motion	
§4.71a Rating	0%	0%	0%	0%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee degenerative joint disease and symptomatic arthritis condition 10%, coded 5299-5003 (degenerative arthritis).  The PEB also listed status post bilateral high tibial osteotomies as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the status post bilateral high tibial osteotomies was properly subsumed under the overall rating for the bilateral knee degenerative joint disease and symptomatic arthritis IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  Although the CI did undergo a VA C&P examination, no VA rating was received and it was reported that the CI cancelled the claim.  The panel noted that each knee had surgery, each had limited and painful motion, and both had degenerative changes.  The evidence supports a finding that each knee was separately unfitting.  

The panel concluded that there was sufficient evidence of painful motion and functional loss to support a 10% rating for each knee IAW §4.59 and §4.40.  Although the CI gained considerable weight following accession, no examiner attributed a limitation in motion to his body habitus.  The panel also observed that while his obesity would aggravate the pain present in any weight bearing joint, no deduction is made for this.  In considering routes to a higher rating, there was no limitation of motion which attains a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257).  Meniscal tears were reported for both knees with surgery on the right twice, supporting a 10% rating for a history of surgery to remove a meniscus (5259) on the right.  However, both knees also had an HTO procedure which supported consideration under the respective codes for knee impairment related to impairment of the tibia (5262).  As signs of meniscal irritation were not specifically recorded proximate to separation, this is thought to be the more appropriate code.  The panel noted that a single rating is permitted for each knee for limited, painful motion even if more than one code is applicable.  There was therefore no VASRD §4.71a route to a rating higher than 10% for each knee under any applicable code, and no grounds for additional rating based on the presence of instability.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommended a disability rating of 10% for the right knee condition and 10% for the left knee pain condition, coded 5262.

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel unanimously recommends a disability rating of 10%, coded 5262 for the right knee and a disability rating of 10%, coded 5262 for the left knee IAW VASRD §4.71a.  There were 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Knee Pain	5262	10%	
Left Knee Pain	5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 12 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 02 Aug 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 07 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 14 Jul 17 ICO XXXXXXXXXXXXXXXXXX

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

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

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

     c. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Temporary Disability Retired List for six months beginning date of discharge with a 60 percent combined disability rating and a final rating after six months of 20 percent.  

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 60 percent rating (increased from 20 percent) effective date of discharge.       

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

     f. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 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.

	XXXXXXXXXXXXXXXXXX
	Acting