RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01484
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040512

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Airman, medically for “right anterior cruciate ligament [ACL] reconstruction with complex region pain syndrome [CRPS]” with a disability rating of 20%.

CI CONTENTION:  “PTSD, RSD, nerve damage, right leg atrophy, on Canadian crutches or wheelchair, 3 surgeries on right leg back to back.”  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 - 20040204	VARD - 20050826	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right ACL reconstruction with…CRPS	5299-5003 	20%	Post-Op Residual…Right …ACL…	5010-5257	10%	20050419	
			CRPS…Right Lower Extremity	8599-8520	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right ACL Reconstruction with CRPS.  The PEB combined the ACL reconstruction and CRPS conditions under a single disability rating, coded analogously to 5003 and rated 20%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled 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.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the ACL reconstruction and CRPS conditions is presented together, but with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right knee condition was first noted at a primary care visit on 19 September 2001 when she reported that it “popped out” while climbing stairs and acknowledged a history of the same prior to enlistment.  On examination, her gait was normal, but painful motion and an effusion were present, and she was treated with medications and light duty.  The next STR entry on 4 March 2002, noted reports of right knee pain onset during “boot camp,” but without specific trauma.  Signs of meniscal damage were present on examination.  An X-ray was normal, but an MRI showed ACL, medial meniscal and lateral meniscal tears.  The medical and lateral meniscal tears were surgically repaired on 27 July 2002.  The CI then underwent rehabilitation for the ACL insufficiency, which was unsuccessful, and she had an ACL reconstruction on 17 December 2002.  She developed arthro-fibrosis (scarring in the joint) which was manipulated under anesthesia on 30 January 2003 with full motion obtained.  

During the 31 March 2003 limited duty (LIMDU) board examination, the CI endorsed limited and painful right knee function, and the examiner noted she had been unable to attend physical therapy appointments due to transportation issues.  Physical examination revealed atrophy but no instability.  Flexion was to 135 degrees (normal 140), with pain at the end of motion.  The examiner diagnosed “probable” CRPS in addition to pain status post ACL repair, and recommended a second LIMDU period.  An April 2003 bone scan was consistent with the knee pathology (but changes associated with CRPS were not recorded), and subsequent injections did provide pain relief.  In orthopedics on 30 July 2003, range of motion (ROM) was 0-115 degrees, with no effusion or ACL deficiency; medications for the CRPS were not successful.  On 16 September 2003, the orthopedist documented an antalgic gait, ROM of 1-115 degrees and no instability; the CI was sensitive to light touch.  

The 30 October 2003 MEB NARSUM orthopedic examination, 6 months prior to separation, noted complaints of persistent pain, even with light touch, despite extensive rehabilitation and medical treatment.  Physical examination showed thigh atrophy but no effusion or instability.  There was “speckling” of the skin over the thigh near the knee, but neurovascular findings were normal (changes which are frequently seen with CRPS were not recorded).  Measured ROM was -3-135 degrees and painful.  During the 5 December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months before separation, the CI reported that her right knee remained painful and gave way.  The physical examination did not record specific knee pathology.  

At the 19 April 2005 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported ongoing right knee pain, but denied incapacitation; she worked as a truck driver.  Physical examination showed no distress and normal gait and weight bearing without the use of an assistive device.  Measured ROM was 0-140 degrees and not limited by pain on repetition.  The knee was diffusely tender to light touch and the right lower leg hypersensitive to touch below the knee to the foot.  The examiner recorded that McMurray’s testing was “abnormal with slight instability” (however, this provocative test is for meniscal irritation and not expected to be positive given the repairs of both menisci).  A drawer test for instability was normal and skin changes associated with CRPS were not present.  The left knee and both ankle reflexes were 1+, but the CI refused reflex testing of the right knee (which was then recorded as absent).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ACL reconstruction with CRPS 20%, analogously coded 5299-5003 (arthritis, degenerative).  The VA rated the right knee condition 10%, dual coded 5010-5257 (arthritis due to trauma-knee, other impairment), based on the C&P examination, citing instability.  The VA also rated the CRPS 10%, analogously coded 8599-8520 (sciatic nerve paralysis), noting increased sensitivity, an absent right knee reflex, and a 1+ ankle reflex.

The panel first considered whether the right knee and CRPS remained separately unfitting, having decoupled them from the combined PEB adjudication. The LIMDU restrictions specifically implicated both conditions, and the MEB NARSUM documented separate medical histories.  Members agreed that either condition would have rendered the CI incapable of continued military duties and accordingly recommends separate service ratings for the right knee and CRPS.

The panel agreed that the right knee would warrant a 10% rating for a symptomatic removal of the menisci under code 5259.  The limitation in motion was not ratable under a specific knee code, and painful motion, when present, is subsumed under the 5259 rating.  The CRPS condition was manifested by subjective pain and hyper-sensitivity, and atrophy was documented a few months after the second surgery.  The CI was able to perform all activities of daily living and denied incapacitation, but experienced pain with walking, climbing, and prolonged sitting or standing.  Members determined this was consistent with a mild nerve impairment analogous to code 8520 which supports a 10% rating.  However, the panel noted that these separate 10% ratings offered no rating advantage to the CI.  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 ACL reconstruction and CRPS condition.

BOARD FINDINGS:  In the matter of the ACL reconstruction and CRPS condition and IAW VASRD §4.71a and 4.124a, the panel 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 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN