RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00690
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E-5, Aircraft TACAN/Radio Navigation Equipment IMA Technician, medically separated for “complete posterior cruciate ligament (PCL) tear, right knee” and “questionable degenerative medial meniscus tear with tibial femoral changes on the medial side, left knee,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “The military didn’t take into consideration my head injury.”  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 – 20031218	VARD - 20040721	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee, Complete PCL Tear	5257	10%	Right Knee S/P Partial Anterior Cruciate Ligament (ACL) and Complete Posterior Cruciate Ligament (PCL) Tear	5257	20%	20040218	
Partial ACL Tear with Questionable Function	Cat II					
Posterolateral Corner Insufficiency	Cat II	Right Knee Chondromalacia Patella and S/P Displaced Tibial Plateau Fracture	5260	10%		
Patellofemoral Arthrosis	Cat II					
Left Knee, Questionable Degenerative Medial Meniscus Tear 	5299-5003	10%	Left Knee Chondromalacia Patella	5260	10%		
Patellofemoral Arthrosis	Cat II					
Posterolateral Corner Insufficiency	Cat II					
Complete PCL Tear, Asymptomatic	Cat II	Left Knee Complete PCL Tear and Posterior Lateral Deficiency	5257	20%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Knee Complete PCL Tear.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent a right knee closed reduction of posterior dislocations on 11 August 2001, with a follow-up 24 August 2001 arthroscopy that included debridement of osteochondral fracture fragments, partial medial and lateral meniscectomy, and debridement of the PCL and ACL.  

At the 22 October 2003 MEB NARSUM examination, 6 months prior to separation, the CI reported right knee pain and instability.  The right knee swelled with associated episodes of partial giving way approximately every 3-4 days and occasional quadriceps fatigue causing the knee to give way.  The physical examination showed right knee range of motion (ROM) of 0-135 degrees (normal 0-140) with crepitus.  There was a grade 1-2 pivot shift and a positive Lachman demonstrating approximately 5 mm of anterior translation (instability) with a solid endpoint, likely representative of a partial tear of the ACL with partial functioning.  PCL evaluation demonstrated a positive drawback or sag with 8 to 10 mm of posterior translation (instability).  Surgical correction of the right knee via staged procedures was discussed, but would have required a minimum of two periods of extended limited duty.  

At the 14 February 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported instability and pain in his right knee.  Physical examination of the right knee showed no effusion and the CI was wearing a hard knee brace.  ROM was 0-135 degrees (normal 0-140) with painful motion.  There was positive patellar compression and a positive inhibition sign.  Measurements of instability noted lateral translation in medial and lateral directions at 5 mm and 4 mm respectively, while the Lachman’s test showed 5 mm of anterior translation (all positive signs for instability and a partial ACL tear).  The examiner also noted positive translation of the PCL (indication of instability).  MRI of the right knee dated 25 February showed edema within the anteromedial tibial plateau with contour irregularities and abnormal appearance of the medial meniscus and blunting of the lateral meniscus.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5257 (knee, other impairment of: recurrent subluxation or lateral instability).  The VA rated the right knee at 20% under code 5257 (knee, other impairment of: recurrent subluxation or lateral instability), and 10% under code 5260 (leg, limitation of flexion of), citing limitation of motion with pain and instability for the right knee.  

The PEB listed associated diagnoses (Category II) of “partial ACL tear with questionable function” and “posterolateral corner insufficiency”; however, these conditions are also conditions ratable under the PEB’s 5257 (instability) coding.  They are not separable from the PCL condition and no additional rating may be assigned (IAW §4.14, avoidance of pyramiding).  Panel members considered the objective findings and associated disability for rating the right knee PCL tear with ACL and posterolateral corner insufficiency (instability).  Both the NARSUM and pre-separation VA examinations documented instability of the PCL and ACL as well as moderate functional disability with respect to instability.  The panel adjudged that with respect to the right knee instability, there was sufficient evidence of “moderate” subluxation or lateral instability to support a 20% rating under the 5257 code (knee, other impairment of).  

The PEB additionally listed patellofemoral arthrosis as a Category II condition (conditions that are related to the primary unfitting condition and contributes to the primary unfitting condition).  The panel’s first charge for this Category II condition is to assess whether it can be reasonably justified as separately unfitting for rating consideration.  The panel considered if the patellofemoral arthrosis (degenerative cartilage) diagnosis and associated painful motion was reasonably unfitting and separately compensable.  When considering a separate rating for Category II conditions, the panel considers each condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  

The CI consistently complained of both instability and painful motion of his right knee.  There was radiographic evidence of degenerative changes as well as meniscal pathology of the right knee.  The panel concluded there was not a preponderance of evidence in the STR which overcame the panel’s presumption that the Category II right knee patellofemoral arthrosis condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right knee patellofemoral arthrosis condition at the time of separation.  The panel noted that an evaluation under 38 CFR 4.71a, code 5257, does not pyramid with evaluations based on limitation of motion or painful motion.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was a history of meniscal surgery, but given the use of symptoms under the above rating under code 5257 there was insufficient evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a higher rating under that code.  There was a fracture of the tibia to support consideration under code 5262 (tibia and fibula, impairment of), but given the use of symptoms under the above rating under code 5257 there was insufficient evidence for dual rating the knee any higher that 20% (instability) plus 10% (painful motion) given the tenants of VASRD §4.14 (avoidance of pyramiding).  Combining all of the CI’s right knee symptoms and rating analogous to code 5262, was considered, but would not provide any higher rating and would be of no benefit to the CI.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the right knee, complete PCL tear condition (with partial ACL tear with questionable function, and posterolateral corner insufficiency), coded 5257; and recommends a separately unfit determination with a disability rating of 10% for the right knee patellofemoral arthrosis condition (dual knee rating), coded 5299-5003 (analogous to degenerative arthritis).  

Left Knee (Left Knee, Questionable Degenerative Medial Meniscus Tear with Tibial Femoral Changes on the Medial Side).  According to the STR and MEB NARSUM, the CI underwent a closed reduction of posterior dislocations on 11 August 2001, followed by left knee arthroscopy on 20 August 2001 to include a partial medial meniscectomy and debridement of cartilage and a complete tear of the PCL.  At the 22 October 2003 MEB NARSUM examination the CI reported left knee pain without episodes of left knee swelling or giving way.  The physical examination showed left knee ROM of 0-135 degrees (0-140 normal) with crepitus.  

There was mild anterior compression pain with translation of 4 mm medially and 30% laterally.  There was tenderness at the joint line (“likely representative of degenerative changes”).  Lachman’s (ACL test) was negative.  The PCL demonstrated 10 to 11 mm of drawback with a positive endpoint (laxity/instability).  The collateral ligaments showed 10 mm opening medially and laterally at 30 degrees (laxity/instability).  Continuing evaluation of the left knee was recommended without surgery, unless symptoms increased.  

At the C&P evaluation the CI reported pain in his left knee with knee extension.  Physical examination of the left knee showed ROM of 0-135 degrees with crepitus and tenderness over the patella, positive patellar compression and positive inhibition sign.  Lachman's test (ACL) was negative.  PCL testing showed a sag with 10 to 11 mm of drop back, and the collateral ligaments demonstrated opening 10 mm medially and laterally at 30 degrees.  MRI of the left knee showed edema within the medial femoral condyle and abnormal appearance of the medial meniscus with irregularities of the femoral articular cartilage.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5299-5003.  The VA rated the left knee 10% under code 5260, citing limitation of motion with pain.  The VA also rated the left knee 20% under code 5257, citing instability.  

The PEB listed associated left knee Category II diagnoses of “patellofemoral arthrosis,” “posterolateral corner insufficiency” and complete PCL tear, asymptomatic.”  As discussed above, the panel’s first charge for this Category II condition is to assess whether it can be reasonably justified as separately unfitting for rating consideration.  The patellofemoral arthrosis would be rated under the same criteria as the primary unfitting condition for painful or limited motion and is not separately ratable considering the tenants of VASRD §4.14 (avoidance of pyramiding).  The posterolateral corner insufficiency, and “complete PCL tear, asymptomatic” conditions relate to instability, and the panel deliberated if left knee instability was reasonably unfitting.  

Although there was evidence of significant PCL (and collateral ligament) laxity on both NARSUM and VA examinations, left knee instability was not a significant complaint or symptom for the left knee.  The PEB disability description indicated the left knee complete PCL tear was asymptomatic, and was considered an implied “not unfitting” determination.  The posterior corner insufficiency would also contribute to instability and knee symptoms.  The panel adjudged that with respect to the left knee instability, there was not sufficient evidence of instability impairing duty function and the panel adjudged that no additional left knee Category II condition was additionally unfitting and/or separately ratable.  

With respect to the left knee “questionable degenerative medial meniscus tear with tibial femoral changes on the medial side” condition, there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was functional loss with decreased endurance and symptoms of pain associated with meniscal pathology/surgery supporting a 10% rating (based on §4.40 and §4.45) as found on the NARSUM and VA examinations.  Ideal coding analogous to code 5259 was considered, but would offer no rating higher than the 10% adjudicated by the PEB.  There was insufficient evidence of left knee frequent episodes of “locking,” pain, and effusion into the joint to warrant a higher rating under code 5258.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 left knee condition.  

BOARD FINDINGS:  In the matter of the right knee condition the panel unanimously recommends dual knee rating with a disability rating of 20%, coded 5257 (for the complete PCL tear, with partial ACL tear with questionable function and, posterolateral corner insufficiency); and a disability rating of 10% for an unfitting right knee patellofemoral arthrosis condition coded 5299-5003, both IAW VASRD §4.71a.  In the matter of the left knee condition 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 recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Knee, Complete PCL Tear (with Partial ACL Tear with Questionable Function and Posterolateral Corner Insufficiency)	5257	20%	
Right Knee, Patellofemoral Arthrosis	5299-5003	10%	
Left Knee, Questionable Degenerative Medial Meniscus Tear with Tibial Femoral Changes on the Medial Side (with Patellofemoral Arthrosis)	5299-5003	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160914, w/atchs
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 12 Feb 18 ICO XXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 17 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 12 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 17 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 17 Feb 18 ICO XXXXXXXXXXXXXXXXXX    
	(h) PDBR ltr dtd 17 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 12 Feb 18 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 as follows:

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

     c. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.     

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.   

     e. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent 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.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List at time of discharge for six months with a 50 percent rating followed by a permanent rating of 10 percent with entitlement to disability severance pay. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXX
                                  Acting