RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02433
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Electrician’s Mate, medically separated for “bilateral, patella dislocation” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that both knees were surgically repaired yet he continues to suffer from chronic pain and limited range of motion.  

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 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 - 20050224	VARD - 20050817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral, Patella Dislocation	5099-5003	10%	Right Knee Recurrent Dislocations Status Post Tibial Tubercle Osteotomy	5257	0%	20050628	
			Left Knee Recurrent Dislocations Status Post Tibial Tubercle Osteotomy		0%		
S/P Bilateral Fulkerson Procedure 	Cat II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral, Patella Dislocation condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported a history of knee dislocations that occurred in high school which were resolved by the CI pushing the patella dislocation back in.  After joining the military, the CI’s right knee condition became an issue in October 2002 following running.  In November 2003, the CI complained of right patellar instability and anterior knee pain.  The CI’s left knee condition became an issue in June 2003 when he fell from his rack.  Radiographic studies initially showed significant instability of the left and right patella.  In January 2004, the CI underwent an open tibial sliding osteotomy with a second surgery a few days later due to infection.  In June 2004, the CI underwent an open tibial sliding osteotomy of the right knee.  Post-surgery radiographic studies showed well-healed tibial tubercle osteotomy with no evidence of acute bone or joint abnormalities in either knee.  

The 26 Jan 2005 MEB NARSUM examination, 3 months prior to separation, noted the CI complained of anterior knee discomfort as well as a sensation of his knees giving way.  He continued to describe discomfort with kneeling, stair climbing, and increase cardiovascular activities for which he took anti-inflammatories.  The physical examination showed no edema, no erythema, no ecchymosis, no significant effusion to either knee, negative Lachman (ligament integrity), negative anterior drawer (instability test), and negative neurovascular findings.  He had full range of motion (ROM) in both knees with retropatellar crepitus, but painful motion was not recorded.  It was noted that radiographs of both knees showed no significant bony abnormality.
	
During the 7 February 2005 MEB examination (recorded on DD Forms 2807 and 2808), 2 months prior to separation, the physical exam showed bilateral crepitus over patella, no tenderness to palpation, and no instability of the ligaments.  

At the 26 June 2005 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported knee stiffness on cold mornings which resolves with normal use.  He had no other symptoms and used no medication.  The physical exam showed well healed scars, no fatigue, weakness, or lack of endurance, and knee instability was absent.  ROM recorded 130 degrees (140) bilateral knees, and painful motion was absent.  

The panel directed attention to its rating recommendation based on the above evidence. 

The PEB rated the knee condition 10%, coded 5009-5003 (arthritis, degenerative).  Status post bilateral Fulkerson procedure was rated Category 2, contributing to the unfitting knee condition, but not separately unfitting.  The PEB administered a 10% deduction for the knee conditions being considered EPTS.  

The VA rated the right knee condition 0% coded 5257 (knee, other impairment of) and left knee condition 0% coded 5257 (knee, other impairment of) based on the VA C&P examination 2 months after separation, citing full recovery and “very good function and essentially no symptomatology.”  
 
The panel directed attention to the clinic visit on 20 November 2003.  The CI detailed he had patella instability in both knees while in high school, and at times, needed to manually push the patella dislocation back in to place.  The NARSUM physician recorded his condition did not exist prior to entry.  Additionally, this information was not detailed during the admission examination.  Panel members concluded, although the CI reported he had problems with his knees prior to service entry, the NARSUM noted the conditions were not present prior to entry, and there was insufficient evidence at the time of service entry to rate the level of knee impairment prior to military service.  Therefore, based on the preponderance of evidence a deduction could not be upheld.  

Additionally, the panel opined the status post bilateral Fulkerson procedure condition was a corrective procedure aimed at addressing the primary condition of bilateral patella dislocation 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 panel recommends a disability rating of 10% for the right knee and 10% for left knee condition, coded 5009-5003, with no deduction for EPTS applied, for a combined rating of 20%.  

BOARD FINDINGS:  In the matter of the right knee condition, the panel recommends a disability rating of 10%.  

In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a with no deduction for EPTS condition.  There are no other conditions within the panel’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	
Right Knee (Called Bilateral Knee)	5099-5003	10%	
Left Knee (Called Bilateral Knee)	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150929, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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 07 Jul 17 XXXXXXXXXXXXXXXXXX
 
	(c) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(d) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(e) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(f) PDBR ltr dtd 03 Aug 17 XXXXXXXXXXXXXXXXXX

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

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

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

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

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

     e. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 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