RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE: pd-2016-01236
BRANCH OF SERVICE:  navy	SEPARATION DATE:  20040109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Operations Specialist, medically separated for “chondromalacia patella, left knee” with a disability rating of 10%.  The PEB also determined “spondylolysis L5” and “degenerative disc disease” both existed prior to service (EPTS) and were not rated.

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 - 20031126	VARD - 20040824	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patella, Left Knee	5299-5003	10%	Osteoarthritis Knees	5010	20%	20040525	
Spondylolysis L5	EPTS	Low Back Strain with Disc Herniation and Spondylolisthesis	5243	20%	20040525	
Degenerative Disc Disease (DDD)						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Left Knee Chondromalacia Patella.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the left knee condition began in November 2002 while playing flag football.  The CI underwent a left knee arthroscopy in April 2003 which ruled out anterior cruciate ligament and meniscus tears.  The 15 September 2003 MEB NARSUM examination, 4 months prior to separation, revealed a normal gait.  There was no left knee physical examination performed.  The examiner opined the CI had done reasonably well without repeat left knee mechanical symptoms since the injury.

During the 25 April 2004 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported constant left knee pain which felt tight and was aggravated by walking and bending.  The knee could give out if the CI stepped wrong on uneven ground; the CI reported falling down once a month when this happened.  Physical examination showed a normal gait.  There was mild knee swelling and patella tenderness, and stability testing was negative.  Range of motion (ROM) was 0 to 140 degrees (normal extension 0 to flexion 140); painful motion was not elicited.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5299-5003 (arthritis, degenerative).  The VA rated a bilateral knee condition 20%, coded 5010 (arthritis, due to trauma), based on the C&P evaluation, citing two major joints with occasional incapacitating exacerbations.  The panel agreed there was no limitation of flexion or extension to support a rating higher than the 10% adjudicated by the PEB under codes 5260 and 5261.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those codes.  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).  The PEB only adjudicated the left knee condition; therefore, coding for two major joints was not applicable in this case.  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 there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.

Spondylolysis L5 and DDD.  The panel first consider if the unfitting EPTS L5 spondylolysis and DDD conditions were permanently service aggravated (PSA), and therefore compensable.  The panel agreed with accepted medical principles that spondylolysis can be present at birth (genetic weakness of the pars interarticularis) or can occur through injury (repeated stress fractures caused by hyperextension of the back (as in gymnastics and football) or by traumatic fractures.  

The 1 September 2003 neurological evaluation stated:  “At this time, within a reasonable degree of medical probability, [the CI’s] need for treatment and care is based on the [football] assault and not on the pre-existing pars defect.”  Additionally the CI’s August 2001 service entry Reports of Medical Examination and History (DD Form 2807-1) did not document any spinal defects or diagnoses.  The CI did not seek medical attention for a back condition until November 2002 following, and due to, his football injuries.  The CI was subsequently placed on limited duty for his back condition.  The panel determined that presumption of service aggravation was not overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of the CI’s military service.  Therefore, the back condition was determined to PSA and eligible for disability compensation

According to the STR and MEB NARSUM, the CI’s back condition began in November 2002 while playing flag football.  X-rays and an MRI revealed L5 spondylolysis and L4-5 and L5-S1 DDD.  The CI was a candidate for a lumbar fusion, but did not undergo the procedure.  The 15 September 2003 MEB NARSUM examination, 4 months prior to separation, reported back pain with occasional right lower extremity numbness episodes.  Physical examination showed a normal gait.  Lumbar ROM was “essentially full”; painful motion, posture, spinal tenderness, and muscle spasms were not addressed.

During the C&P evaluation the CI reported back pain due to prolonged sitting (longer than half an hour) which was also aggravated by standing and lifting.  The pain radiated down the back of the right leg to the calf.  Physical examination showed a normal gait, and the ability to walk on his toes and heels, and arise from a squat without problems.  There was spinal tenderness.  ROM was flexion to 90 degrees (normal) and combined ROM was 220 degrees (normal 240); painful motion was elicited.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate either unfitting back condition, as both were considered EPTS (and not PSA).  The VA rated the back condition 20%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P evaluation 5 months after separation, citing incapacitating episodes.  The two unfitting PEB back conditions are not separable due to symptom attribution and are rated together under the VASRD General Spine Formula.  The MEB NARSUM’s “essentially full” ROM may have indicated combined ROM less than 240 degrees, to support a 10% rating.  However, the panel agreed that a 10% rating was justified for the presence of painful motion or spinal tenderness, as reported on the VA examination which was more comprehensive, corroborated by the STR, and held a higher probative value than the equidistant MEB NARSUM examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  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 back condition, coded 5243.

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the back condition, the panel unanimously recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation.

CONDITION	VASRD CODE	PERMANENT RATING	
Chondromalacia Patella, Left Knee	5299-5003	10%	
Spondylolysis L5 and Degenerative Disc Disease	5243	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160928 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 01 Mar 18 ICO XXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 20 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 13 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 02 Oct 17 ICO 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 USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List at time of discharge for six months with a disability rating of 50 percent followed by transfer to the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent).

     c. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 50 percent rating (increased from 0 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: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.   
     
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.