RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01420
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20040515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Seaman Recruit, medically separated for “chondromalacia of the patella, Grade III, right knee, status post-surgical debridement” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20040309	VARD - 20060215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Of The Patella, Grade 3, Right Knee, Status Post-Surgical Debridement	5299-5003	10%	ACL Tear / Chondromalacia Of The Patella, Grade 3, Right Knee, Status Post-Surgical Debridement	5257	NSC	STR	
Anterior Cruciate Ligament Tear, Right Knee	Not Unfitting / Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chondromalacia of the Patella, Grade 3, Right Knee, Status Post-Surgical Debridement.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in July 2003 as a result of a basketball injury.  On 19 August 2003, the CI underwent arthroscopy where an anterior cruciate ligament (ACL) partial tear was demonstrated with a large lobular node and a markedly injected ligamentum mucosum (infrapatellar plica, an embryological remnant of a synovial septum).  The ligamentum mucosum and the area of injection were resected to better define the pathology and the ACL was then debrided.  The medial and lateral menisci were intact, but the medial meniscus was highly mobile, was subluxed anteriorly, and the tibial plateau anteromedially was not covered by meniscus.  Chondromalacia patella, Grade II-III of the superior-medial facet, was also noted.  The CI was subsequently placed in a program of physical therapy PT.  

At the 17 September 2003 orthopedic clinic appointment, the CI complained of persistent discomfort and stiffness.  A moderate effusion was present, which was aspirated and injected with a steroid/anesthetic combination.  At the 10 October 2003 orthopedic clinic visit, the effusion persisted and was again aspirated.  At the 31 October 2003 orthopedic clinic appointment, the effusion was decreased, but the CI complained of weakness and his knee gave way once.  

At a PT visit on 5 November 2003 the CI reported no significant pain, but there was stiffness.  The CI used ice and stretching to alleviate the stiffness.  Physical examination showed an increase in laxity of the right anterior cruciate ligament with continued instability.  On examination, the right knee range of motion (ROM) was 3-125 degrees (normal 0- 140).  At the 19 November 2003 orthopedic visit the CI continued to complain of right knee pain and giving way.  There was a minimal effusion.  Lachman’s test (to determine laxity) and McMurray’s test (to determine a meniscal tear) were negative.  At the 3 December 2003 PT appointment, the CI reported “buckling” that occurred two to three times per week.  Examination of the right knee showed a mild increase in warmth and tenderness.  The CI had a normal gait.  There was some quadriceps atrophy noted and increased laxity with Lachman’s testing.  McMurray’s test was again negative.  Right knee ROM flexion was 3-125(normal 0-140) degrees with painful motion.  An MRI dated 8 December 2003 revealed a complete rupture of the ACL and a complex, but predominantly oblique, tear of the posterior horn of the lateral meniscus.  There was also a moderate knee effusion.  

The 11 December 2003 MEB NARSUM examination, 6 months prior to separation, noted complaints of persistent right knee pain.  Based on the MRI findings, the CI was given the option of a second debridement of the knee and possible ACL repair; however, he declined any further surgery.  Physical examination showed a moderate effusion of the knee.  There was also minimal tenderness in the lateral joint line.  The knee was stable medially and laterally and a drawer test of the right knee showed minimal laxity in the anterior plane of the knee.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chondromalacia of the patella, Grade III, right knee, status post-surgical debridement condition 10%, coded 5299-5003 (arthritis, degenerative).  The PEB also listed ACL tear, right knee as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the ACL tear, right knee was properly subsumed under the overall rating for the chondromalacia of the patella, Grade 3, right knee, status post-surgical debridement IAW §4.14 (avoidance of pyramiding).  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The panel considered use of code 5258.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions to support a rating under that code.  Although the CI reported his knee giving way and buckling, he did not report frequent locking.  At the time of surgery, the medial meniscus was noted to be subluxed and did not cover the tibial plateau anteromedially.  The CI did have postoperative effusions that persisted despite aspirations and injections, and pain was present with motion.  Although a meniscal tear was demonstrated on the MRI in December 2003, it was not dislocated nor was there a loose body present.  Therefore, the panel determined that code 5258 was not applicable.  Code 5259 (cartilage, semilunar, removal of, symptomatic) was likewise inapplicable in the absence of meniscal surgery. 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).  Therefore, there was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable knee 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 right knee condition.  

BOARD FINDINGS:  In the matter of the right 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.  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 20161010, 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:

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