RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02536
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20020205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty  E5, Stinger Anti-Terrorist Weapon (ATW) Operator and Maintenance, medically separated for “persistent left anterior cruciate ligament insufficiency” with a disability rating of 10%.  

CI CONTENTION:  “Still having pain issues in left knee.  Due to trying to compensate, am now having pain in right knee and both hips.”  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 - 20011030	VARD - 20030828	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Left Anterior Cruciate Ligament Insufficiency	5257	10%	Residuals, Left Knee ACL Repair	5003-5259	10%	20030616	
Degenerative Joint Disease, Left Knee	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Persistent Left Anterior Cruciate Ligament Insufficiency.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgery in October 2000 for a cadaver replacement of his anterior cruciate ligament and partial removal of the lateral and medial menisci.  He continued to have pain and recurrent instability.  The CI underwent as second surgery in July 2001 for a medial meniscal partial resection and removal of a prominent screw from the first operation.  Following surgery further treatment did not sufficiently resolve the left knee pain and instability.  

The 10 September 2001 MEB NARSUM, 5 months prior to separation, the CI had complaints of instability and pain in his left knee.  The physical examination noted a range of motion (ROM) of flexion to 125 degrees (normal 140) and extension of 0 degrees (normal).  There was normal resistance to varus and valgus stresses at 0 and 30 degree.  There was a 2+ Lachman with no firm end point signifying an incompetent anterior cruciate ligament with instability and he had slight tibial glide.  

At the 12 June 2003 VA Compensation and Pension (C&P) examination, 16 months after separation, the CI reported  that he continued to have constant pain rated at 5 out of 10.  Knee pain was aggravated by going up and down stairs, walking on inclines, sudden sidestep movement, and walking greater than 100 yards.  The CI also stated that his knee would give way, lockup, and was easily fatigued.  He complained of dislocations of the knee; however, since he had been out of the military it had only happened once.  The physical examination showed that the CI walked with a slight limp towards the right favoring his left knee.  He was able to do tandem walk, walk on his heels and toes and he had normal strength.  The left knee had full ROM, positive crepitus with stated pain and facial grimacing, positive McMurray’s test (test for meniscus damage), negative drawer sign bilaterally and the patella was stable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee pain condition 10%, coded 5257 (knee, other impairment of, slight instability).  The Navy PEB also listed degenerative joint disease, left knee as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  Panel members agreed the impairment from the left knee degenerative joint disease was improperly subsumed under the overall rating for the left knee instability from persistent anterior cruciate ligament insufficiency and that a separate rating did not violate VASRD §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the left knee condition 10%, dual coded 5003-5259 (arthritis, degenerative-cartilage, semilunar, removal of, symptomatic), citing painful or limited motion.  

There was evidence recurrent left knee instability as demonstrated by the CI’s complaints of instability and the 2+ Lachman test with no firm end point at the MEB NARSUM evaluation to support a 10% rating under code 5257.  

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 persistent left anterior cruciate ligament insufficiency condition.  

Degenerative Joint Disease Left Knee.
There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was a history of surgery to remove a meniscus to support a 10% rating under code 5259.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  

The panel agreed that the preponderance of the evidence with regard to the functional impairment of degenerative joint disease, left knee favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5259 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the persistent left anterior cruciate ligament insufficiency condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  

In the matter of the degenerative joint disease, left knee the panel unanimously agrees it was separately unfitting and recommends a disability rating of 10% for (painful motion, symptomatic cartilage removal) coded 5259 IAW VASRD §4.71a.  

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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Persistent Left Anterior Cruciate Ligament Insufficiency	5257	10%	
Degenerative Joint Disease (Left Knee Pain)	5259	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151030, w/attachments
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