RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00139
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20081002

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Aviation Structural Mechanic Airman, medically separated for “right knee instability” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20080729	VARD - 20081203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Instability	5257	10%	Residuals Right Knee Status Post ACL Reconstruction	5260	0%	20081028	
Status Post Medial Meniscus Repair (R)	Category II					
Status Post Debridement, Lateral Meniscus (R)						
Status Post ACL Reconstruction (R)						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Knee Instability (Subsuming Category II Surgical Residuals).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI twisted her right knee in August 2007.  She complained of instability and locking; and, imaging (MRI) demonstrated both anterior cruciate ligament (ACL) and meniscal injuries.  She underwent surgical intervention (Category II procedures charted above) in November 2007 (11 months before separation).  Surgical results were insufficient to allow unrestricted duty.  There were no post-operative STR entries that were probative to range of motion (ROM), effusion, instability, impingement or other VASRD-ratable findings.  
The 12 June 2008 NARSUM examination, 4 months prior to separation, documented “multiple twisting injuries postoperatively” and persistent nonspecific pain with subjective instability (no complaint of locking) that prohibited running or sports, but was improving with the use of a brace.  The physical examination recorded tenderness, “minimal effusion” and did not note any objective signs of meniscal impingement.  The examiner described some ACL laxity (Grade II Lachman’s with a firm end point), but the joint was stable to stress in all other planes.  The examiner documented “full” ROM and no objective evidence for painful motion was provided.

The 28 October 2008 VA Compensation and Pension (C&P) evaluation, 2 weeks after separation, documented constant pain and a complaint that the knee “feels weak.”  The examiner stated that there were no symptoms of instability or locking, but noted “occasional” use of brace.  The listed functional limitations were standing limited to 15-30 minutes and walking “more than 1/4 mile but less than 1 mile.”  Physical examination recorded a normal gait without use of a brace, no tenderness or effusion, and the absence of objective instability or meniscal impingement.  Measured ROM was flexion to 140 degrees with 0 degrees extension (both normal), specifying the absence of painful motion or ROM degradation with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  It was first agreed that all of the Category II conditions were intrinsic to the rated condition such that a separate rating could not be supported without pyramiding (VASRD §4.14); thus, they were appropriately subsumed in the same rating.  The PEB’s 10% rating was under code 5257 (knee, other impairment of) which provides for rating of instability: 10% for “slight,” 20% for “moderate,” and 30% for “severe.”  The VA’s 0% rating under code 5260 (limitation of flexion) cited the C&P evidence of normal ROM without painful motion.

Members agreed that there was not satisfactory evidence of painful motion to support a minimum 10% rating.  Painful motion was not specified or implied by the service evidence, and it was specifically refuted by the C&P examiner.  There was no evidence for compensable ROM limitation, persistent effusion and locking, instability, or fracture with nonunion or malunion to support a rating higher than 0% under any code; except for code 5259 (cartilage, semilunar, removal of, symptomatic) which provides for a 10% rating independently of painful motion, and for the PEB’s code 5257, rating only for instability.  

The panel then considered whether a rating higher than 10% was justified under code 5257 per the above criteria; but, members agreed that it was not.  The residual (and fairly modest) instability at the time of the NARSUM was noted to be resolving, a clinical course that was corroborated by the C&P; and, the latter indicated that any instability present at separation was slight at most.  The panel additionally noted that dual rating for limitation of motion and instability was not applicable to this case, given the normal ROM and absence of painful motion.  Code 5259 (see above) would support a stand-alone rating of 10%, but is not applicable to dual rating without limitation of motion or painful motion (VA Training [FAST] Letter 9-98 in effect).  There was thus no VASRD pathway to a rating higher than that of the PEB.  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 of the right knee condition.

BOARD FINDINGS:  In the matter of the right knee condition (subsuming the above Category II diagnoses) and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160312, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN

		
							XXXXXXXXXXXXXXXXXXX
	     				Principal Deputy, Assistant 
						Secretary of the Navy
						(Manpower and Reserve Affairs)
						Performing the Duties of the 
						Assistant Secretary of the Navy
						(Manpower and Reserve Affairs)