RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01352
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20040418

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E4, Boatswain’s Mate, medically separated for “bilateral patellofemoral pain, left worse than right” rated 10% for each knee, with a combined disability rating of 20%.   

CI CONTENTION:  He should have been rated higher for each of his knee conditions.  He continues to be affected by severe pain and instability. 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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20031210	VARD - 20050223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain	5299-5003	10%	Status Post Arthroscopy; Chondromalacia of the Left Patella	5099-5014	10%	20041116	
		10%	Status Post Arthroscopy; Chondromalacia; Degenerative Joint Disease of the Rt Knee	5099-5014	10%	20041116	
Decreased Range of Motion Bilaterally	Cat II					
Left Quad Atrophy 	Cat II	Left Thigh Muscle Atrophy
	5314	10%	20050129	
Chronic Knee and Low Back Pain	Cat II	Degenerative Disc Disease L4-L5, L5-S1	5242	20%	20041116	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent bilateral arthroscopic knee surgery in February 2003 whereby a lateral muscle release was performed and followed up with aggressive physical therapy (PT).  

The 16 July 2003 MEB NARSUM examination, 9 months prior to separation, noted complaints of increasing knee pain, left greater than right, with occasional giving way of the left knee.  Physical examination (PE) revealed global tenderness about the front aspect of each knee.  Evidence of knee instability was not present.  Range of motion (ROM) was recorded as 10-100 degrees for the right knee and 10-120 degrees for the left (normal 0-140).  Left quadricep muscular atrophy was present by noting a 4-centimeter circumference deficit when measured at the top portion of both kneecaps.  

On the same date of the NARSUM, the CI was evaluated by PT which documented the following: “Treatment plan explained to patient; Atrophy of Quadriceps Femoris increases compressive/shear forces on knee joint and results in increased pain.  Goal is to hypertrophy Quadriceps Femoris to alter pain cycle.”  A primary care encounter on 23 September 2003, 7 months prior to separation, noted “painful, but stable knees.”  A rheumatology evaluation on 31 October 2003, 6 months prior to separation, noted large effusions on both knees as well as painful motion.  

At the 19 November 2004 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI complained of bilateral knee pain that caused significant discomfort and made weight-bearing difficult on either leg.  The PE noted that both knees and kneecaps were “stable.” ROM was recorded as 0-110 degrees bilaterally, and limited by pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral patellofemoral pain 10% for each knee (combined 20%), each coded analogously as 5003 (degenerative arthritis).  The PEB listed decreased ROM bilaterally, left quad atrophy and chronic knee and low back pain conditions as related diagnoses (Category II) that contributed to the disability in this case.  The VA also rated the left and right knee conditions 10% each, coded analogously as 5014 (osteomalacia), based on the C&P examination, citing painful or limited motion of a major joint.

The panel agreed the decreased ROM bilaterally, left quad atrophy and chronic knee and LBP were diagnoses related to the bilateral patellofemoral pain and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited). The panel also noted that although the PEB administratively named one of the three Category II conditions chronic knee and low back pain, the PEB also listed low back pain syndrome as a separate Category III condition (not separately unfitting and does not contribute to the unfitting condition).  Panel members concluded that the preponderance of evidence showed the back condition would not have caused the CI to be referred into the DES, nor would the CI have been found unfit due to the back condition. Therefore, no additional impairment rating is recommended for the back condition.   

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on VASRD §§4.59, 4.40 and 4.45).  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 respective 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 5261 code (leg, limitation of extension) was potentially applicable in this case but the 10% rating under that code (based on 10 degrees flexion at the NARSUM examination) would provide no benefit to the CI.  There was therefore no VASRD §4.71a rating higher than the 10% for each knee (as adjudicated by the PEB) under any applicable code.  After due deliberation, considering all 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 bilateral patellofemoral pain.

BOARD FINDINGS:  In the matter of the bilateral patellofemoral pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended decreased ROM bilaterally, left quad atrophy and chronic knee pain and LBP conditions, the panel recommends no change from the PEB determinations as Category II conditions.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel 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 20160927, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN