RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX      	CASE:  PD-2015-02387
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050805

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Heavy Equipment Operator, medically separated for “mild left knee osteoarthritis,” rated at 10%; and “ right knee mild osteoarthritis,” rated at 0% with a combined disability rating of 10%.  

CI CONTENTION:  “Continued pain with heavy grinding in L (left) knee.  Instability, bad infection at time of surgery.  Re-admitted to hospital.”   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 - 20050608	VARD – None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild Left Knee Osteoarthritis	5299-5003	10%	No VA Claim in Record	
Chronic Pain and Disability of the Left Knee	Cat II		
Right Knee Mild Osteoarthritis	5299-5003	0%		
Chronic Pain and Disability to the Right Knee	              Cat II		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Mild Left Knee Osteoarthritis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in 1997 causing him to undergo medial collateral ligament reconstruction surgery.  He re-injured his left knee in November 2002 while running while serving in Japan.  He was evaluated and treated by orthopedics and eventually underwent a second surgery, left knee arthroscopy, synovectomy and hardware removal at the left medical femoral condyle in April 2003.  It was noted that he had mild degenerative changes throughout the left knee at that time. The CI underwent a third surgery in May 2003, arthroscopy, lavage and debridement with synovectomy.  After being released from active duty in October 2003 he continued to have persistent symptoms of pain and after further treatment in the civilian sector he underwent a fourth left knee surgery in November 2004, arthroscopy with partial medial and lateral meniscectomies.  Recent X-rays of the left knee, April 2005, showed post-surgical changes at the medial femoral condyle consistent with a prior MCL reconstruction and some mild joint space narrowing in the medial and lateral compartment.  

Multiple surgeries and further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “secondary localized osteoarthrosis, lower leg,” “pain in joint, lower leg,” and “late effect of sprain and strain without mention of tendon injury” for PEB adjudication.  At the MEB NARSUM examination, the CI reported constant pain in the left knee rated 3-5/10.  He reported that he was unable to perform multiple activities secondary to pain and limitation of both knees.  He was unable to sit on heavy equipment for prolonged periods of time; standing and walking for prolonged period of time caused pain; and repetitive bending and stopping, squatting, crawling and climbing was affected by pain.  The MEB physical examination noted range of motion with 130 degrees of flexion (140 normal) and 0 degrees of extension.  There was mild crepitus and diffuse medial and lateral joint line tenderness.  There was a trace Lachman’s test on the left side and a 1+ anterior drawer. The left knee was stable to varus/valgus stress at full extension and 30 degrees of flexion.  

The Board directed attention to its rating recommendation based on the above evidence.  
The PEB rated the left knee condition 10%, coded analogously as 5299-5003 (degenerative arthritis) with related Category II diagnosis of “chronic pain and disability of the left knee.”  There was no VA claim or rating in the record.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB. The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  There was no route to a higher rating under any applicable code.  The Board opined that the “chronic pain and disability of the left knee” condition was an integral part of the knee pathology and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  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 for the left knee condition

Right Knee Mild Osteoarthritis.  According to the STR and the MEB NARSUM, the CI reported that his right knee pain condition began in the early 1980’s.  He reported that he underwent arthroscopic surgery. His right knee pain persisted and he was seen in September 2002 prior to his deployment to Japan.  He was placed on 6 months limited duty (LIMDU) while deployed.  He continued to receive treatment following his deployment and eventually underwent a second right knee surgery in November 2004 (right knee arthroscopy and partial meniscectomy).  Radiographic studies done June 2002 showed some mild joint space narrowing of the medial compartment.  The STR noted previous MRIs of both knees showing evidence of meniscal tearing.  Following his second surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “secondary localized osteoarthrosis, lower leg,” “pain in joint, lower leg,” and “late effect of sprain and strain without mention of tendon injury” for PEB adjudication.

At the MEB NARSUM examination, 11 April 2005, the CI reported constant pain in the right knee rated 3-5 out of 10.  He reported that he was unable to perform multiple activities secondary to pain and limitation of both knees to include sitting on heavy equipment for prolonged periods of time, unable to operate equipment foot pedals  for more than 20 minutes; standing and walking for prolonged period of time; and repetitive bending and stopping, squatting, crawling and climbing.  The MEB physical examination noted range of motion with 130 degrees flexion and 0 degrees of extension.  There was mild creptitus, joint line tenderness, negative Lachman’s and negative anterior drawer tests.  The right knee was stable to varus/valgus stress at 130 degrees of flexion. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded analogously 5299-5003 (degenerative arthritis) with a related Category II condition, “chronic pain and disability to the right knee.”  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Therefore there was no VASRD §4.71a route to a rating higher than the 10% under any applicable code.  The Board opined that the “chronic pain and disability to the right knee” condition was an integral part of the knee pathology and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  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 right knee pain condition coded 5299-5003. 

BOARD FINDINGS:  In the matter of the “mild left knee osteoarthritis” condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the “right knee mild osteoarthritis” condition, the Board recommends a disability rating of 10%, coded 5299-5003 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee pain	5299-5003	10%	
Right Knee Pain	5299-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150915, 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:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 31 Jan 17 ICO XXXXXXXXXXXXXXXXXX      
	(c) PDBR ltr dtd 31 Mar 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 30 Jan 17 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 04 Apr 17 ICO XXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 31 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 30 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 27 Feb 17 ICO XXXXXXXXXXXXXXXXXX
      	(i) PDBR ltr dtd 17 Jan 17 ICO XXXXXXXXXXXXXXXXXX 

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

     b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

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

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

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

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

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

     h. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 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.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)