RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00342
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20061027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4,  Culinary Specialist, medically separated for “old disruption of the anterior cruciate ligament (ACL)” with a disability rating of 20%.   

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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20060712	VARD - 20061214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Old Disruption of the ACL	5262	20%	Degenerative Joint Disease Right Knee	5257	20%	20060803	
Internal Derangement of the Medial Meniscus, Right Knee	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Old Disruption of the ACL (Right Knee).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right knee surgery in August 2005 for tears of the anterior cruciate ligament (ACL) and the medial meniscus (cartilage) sustained in a sports-related injury.  A 19 December 2005 orthopedic follow-up evaluation, 4 months after surgery and 10 months prior to separation, recorded complaints of intermittent pain above the kneecap.  There was no complaints of popping or giving way.  Physical examination showed mild knee tenderness but no ligament laxity.  Examinations by physical therapy (PT) in January and February 2006 observed a normal gait and normal knee motion.  At an orthopedic clinic follow-up evaluation on 15 March 2006, 7 months after surgery and 7 months prior to separation, the CI reported “doing well” but complained of 1/10 pain.  There was no locking, giving way or buckling of the knee, but the CI sensed that giving way “wants to happen.”  Physical examination demonstrated no swelling or crepitus of the right knee, but tenderness was present.  Significant right thigh atrophy was also noted.  Some laxity of the ACL was present, but it was not disrupted; and the collateral ligaments were normal.  Range of motion (ROM) was noted as “full.”  The non-medical assessment on 19 April 2006 reported the CI could not play sports that involved use of the right knee, and that the CI mentioned feelings of discomfort in the right knee.

Orthopedic re-evaluation on 31 May 2006 recorded that that the CI’s chief complaint was right knee pain, and although there was no locking, and no buckling or frank giving way, he feared the knee was “going to give out.”  He reported that he could straighten his knee.  Physical examination showed significant right thigh atrophy and no knee swelling.  There was knee tenderness, but “no tenderness…on ambulation.”  Some laxity of the ACL was again noted, but it was not disrupted.  All other right knee ligaments were normal and a test for possible meniscal injury was negative.  ROM was noted as “full.”  In a memorandum on 9 June 2006, the CI recorded that pain was produced by surgical screws and that he “must wear a brace at all times because of the looseness.”

During the 20 June 2006 MEB examination (recorded on DD Forms 2807 and 2808), 10 months after surgery and 4 months prior to separation, the CI reported the need to wear a right knee brace.  Physical examination showed right thigh muscle wasting and no ligament laxity.  On the profiling section of the DD Form 2808 the examiner indicated that the CI was unable to return to full duty due to pain.  The 20 June 2006 MEB NARSUM examination noted complaints of right knee pain and subjective instability, described as “a sense that the knee wanted to give way.”  Physical examination showed significant muscle atrophy in the right thigh.  Right knee swelling was absent and ROM was described as full.  Mild laxity of the ACL was present.  Other knee ligaments were intact and a test for possible meniscal injury was negative.  Lateral knee tenderness was present and there was no crepitus of the kneecap.  Painful motion was not specifically mentioned although the examiner stated, “There was no tenderness observed on ambulation of the patient.”  The examiner rendered diagnoses of “old disruption of the anterior cruciate ligament, status post anterior cruciate ligament reconstruction” and “internal derangement of the medial meniscus, right knee, status post debridement, medial meniscal tear.”

At the 3 August 2006 VA Compensation and Pension (C&P) evaluation, approximately 3 months prior to separation, the CI reported constant pain in the right knee that was 8/10 in intensity, and was caused by physical activity but could also occur spontaneously.  He was unable to cook, climb stairs, perform gardening or push a lawn mower, although he could vacuum, walk and shop.  Physical examination showed an abnormal gait that favored the right leg, and the use of a right knee brace for stability.  The right knee showed swelling, tenderness and crepitus.  Right knee flexion was 70 degrees (normal 140) and it lacked 15 degrees of extension (normal 0).  Repetitive motion reportedly showed additional limitation due to pain, although such repetition did not result in additional loss of ROM.  All right knee ligaments and the medial and lateral menisci reportedly showed “a slight degree of instability.”  Based on a radiographic (X-ray), the examiner rendered a diagnosis of degenerative joint disease of the right knee.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 20%, coded 5262 (tibia and fibula, impairment of:  with moderate knee disability).  The PEB also listed “internal derangement of the medial meniscus, right knee, status post debridement, medial meniscus tear” as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The VA also rated the right knee condition 20%, but used the 5257 code (knee, other impairment of, recurrent subluxation or lateral instability: moderate), based on the C&P examination 3 months before separation.  The VA rater cited “slight instability” as a rationale for a 10% rating, but elevated the rating to the next higher evaluation for “additional functional limitations due to pain, fatigue, weakness, lack of endurance and incoordination.”  

The panel agreed the evidence at hand did not describe “marked” knee disability, therefore a 30% rating under the PEB’s coding approach was not justified.  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions to support a rating under the 5258 code.  Although the VA examination reported limited extension that would justify a 20% rating, the panel considered that the limitation of motion measurements from this examination, and other findings such as instability of every ligament and “instability” of cartilage, were inconsistent with any other examinations.  The VA examination was therefore assigned less probative value in the panel’s deliberations, and it was thus concluded there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).   

Regarding a rating under the 5257 code, the panel agreed that the instability in evidence was “slight,” consistent with the 10% rating assigned by the VA, but also concluded that evidence of additional impairment from repetitive use was lacking.  Therefore, even if instability is conceded as in the panel’s scope of review, thereby rendering dual-coding an option, a 10% rating for instability plus 10% via the 5259 code results in a combined disability rating of 20%, which confers no advantage to the CI.  

Finally, the panel agreed that the additional diagnosis determined to be a Category II condition (condition which contributed to the primary unfitting condition but were not separately ratable) was properly subsumed in the above rating recommendation.  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 old disruption of the anterior cruciate ligament condition.    

BOARD FINDINGS:  In the matter of the old disruption of the anterior cruciate ligament condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20160603, w/attachments
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