RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01635
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040721

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Steelworker, medically separated for “post anterior cruciate ligament [ACL] reconstruction right knee” and “degenerative arthritis left knee,” rated 10% each, with a combined disability rating of 20%.  

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 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 - 20040209	VARD - 20040812	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post ACL Reconstruction, Rt Knee	5299-5003	10%	Residuals…Rt Knee ACL Surgery	5257	10%	20040615	
Degenerative Arthritis, Rt Knee	Cat II	Degenerative Joint Disease (DJD), Rt Knee	5010	10%		
Degenerative Arthritis, Lt Knee	5299-5003	10%	Lt Knee DJD	5010	0%		
Degenerative Arthritis, Rt Elbow	Cat III	Rt Elbow Tendonitis & DJD	5010	10%		
Gout		Rt Foot Gout	5017	10%		
		Lt Foot Gout	5017	10%		
Hyperlipidemia		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Post Right Knee ACL Reconstruction.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had chronic right knee pain and underwent a surgical meniscal repair in January 1999.  An MRI in July 2002 showed evidence of osteoarthritis with suspicious cartilaginous injury and an apparent ACL tear, and he underwent an ACL reconstruction in September 2002.  

The 6 October 2003 orthopedic evaluation, 10 months prior to separation, documented right knee crepitation with no effusion or pain.  Lachman’s testing (for laxity) was negative and there was lateral joint line tenderness (meniscal signs).  Right knee range of motion (ROM) was full and the examiner noted 4 cm of right quadricep atrophy; X-rays showed a slight patellar tilt and surgical changes.  The diagnoses included chondromalacia patella, gout, post ACL reconstruction and meniscectomy, and possible lateral meniscus tear.  

The 15 December 2003 MEB NARSUM examination, 7 months before separation, noted CI complaints of right knee pain.  Physical examination referenced the 6 October 2003 orthopedic examination, and a 9 October 2003 right knee MRI, which revealed some mild ACL laxity, posttraumatic patellar changes, and findings consistent with an ACL reconstruction; there was no evidence of meniscal tears aside from mild degenerative changes.  

During the orthopedic evaluation on 14 April 2004, 3 months prior to separation, the CI reported bilateral knee pain and problems with bending and stooping (worse on the right).  Physical examination revealed right knee crepitus with loss of 5 degrees of extension and 15 degrees of flexion.  There was positive anterior compression and lateral joint line tenderness.  Lachman’s testing was negative with slight laxity and there was a mild positive anterior drawer.  The examiner diagnosed bilateral quadriceps tendonitis, patellar chondromalacia and DJD, right worse than left, and limited motion and laxity of only the right knee.  

At the 15 June 2004 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported severe right knee pain and flares.  Physical examination showed a normal gait.  There was a slight degree of recurrent subluxation, but drawer and McMurray tests were negative for laxity and meniscal signs respectively.  Recorded ROM showed flexion to 140 degrees (normal) and extension to 0 degrees (normal) with no pain, fatigue, weakness, lack of endurance, or incoordination; X-rays showed remote ACL repair with mild degenerative changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the post right knee ACL reconstruction condition 10%,” coded 5299-5003 (analogous to degenerative arthritis).  The PEB also listed “degenerative arthritis of the right knee” as a Category II condition (not separately unfitting but contributes to the unfitting condition).  The VA separately rated “residuals of right knee cruciate ligament surgery” 10%, coded 5257 (knee, other impairment of), based on the C&P examination, citing “mild subluxation with full range of motion.” The VA also separately rated right knee DJD 10%, coded 5010 (arthritis due to trauma), citing “full range of motion with tenderness.”  Members noted the PEB rated the knee condition for ACL surgery, accounting for knee instability in the adjudication, and also included knee arthritis as a Category II condition.  However, painful motion or meniscal symptoms are not included in ratings for instability, and the CI had findings of both instability and pain following meniscal surgery with degenerative changes.  The panel therefore concluded that consideration of dual coding for instability and painful motion/symptoms following meniscal surgery was appropriate, and dual rating was considered.  The orthopedic examination proximate to separation and the pre-separation VA examination both documented slight instability, and thus members agreed that there was no greater than slight instability following ACL surgery for any rating higher than 10% (slight) under code 5257.  In deliberating a dual rating for degenerative arthritis of the knee, there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, the persistence of pain with functional loss after meniscal surgery warranted a 10% rating under the 5259 code (cartilage, semilunar, removal of symptomatic).  It was agreed that frequent locking due to dislocated semilunar cartilage was not present, and therefore a 20% rating was not justified under code 5258.  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 knee instability, coded 5299-5257, and 10% for degenerative arthritis and symptomatic cartilage removal, coded 5299-5259, for a combined rating of 20% for the right knee condition.  

Left Knee Degenerative Arthritis.  According to the STR and MEB NARSUM, the CI’s left knee condition began as early as 1999 when urate crystals (indicative of gout) were identified in the knee.  X-rays in November 2001 documented a patellar bone spur or osteophyte.  

The MEB NARSUM examination indicated a history of left knee pain with a prior finding of urate crystals in the joint and X-ray showing degenerative changes from January 2003.  The diagnosis was “degenerative arthritis left knee (mild).”  

A 25 February 2004 orthopedic treatment entry noted the CI was “here for PEB.”  It recorded “10% knee (left),” DJD, right greater than left, and minimal crepitus of the left knee (2+ on the right).  Orthopedic evaluation on 14 April 2004 documented complaints of bilateral knee pain with problems bending and stooping, and X-rays showed “soft tissue calcification at the upper pole of the patella consistent with calcific tendinitis or possibly old injury.”  Physical examination revealed left knee crepitus and tenderness without effusion.  Diagnoses included bilateral knee quadriceps tendonitis, patellar chondromalacia, and DJD (right worse than left).  

At the C&P examination, the CI reported left knee pain with difficulty walking and bending during flares.  Physical examination showed a normal gait, no knee tenderness and ROM of 0-140 degrees with no pain, fatigue, weakness, lack of endurance, or incoordination; X-rays showed calcification in the suprapatellar tendon.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee degenerative arthritis 10%, coded 5299-5003.  The VA rated left knee DJD 0%, coded 5010, citing “full range of painless motion…”  Panel members found no limitation of motion which supported a rating under the diagnostic codes for flexion or extension (5260, 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.  Additionally, 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 panel found no other applicable VASRD code warranting a rating higher than the 10% adjudicated by the PEB.  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.  

Contended PEB Conditions:  Gout, Hyperlipidemia, and Degenerative Arthritis Right Elbow.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were noted on limited duty reports or implicated in the non-medical assessment.  The NARSUM and MEB noted the contended diagnoses, however the NARSUM examiner indicated the CI was solely “impaired from running and excessive walking” with a “chronic problem primarily with his right knee.”  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the post right knee ACL reconstruction and Category II degenerative arthritis condition, the panel recommends a disability rating of 10%, coded 5299-5257; and a disability rating of 10%, coded 5299-5259, respectively, both IAW VASRD §4.71a.  In the matter of the left knee degenerative arthritis condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended gout, hyperlipidemia, and right elbow degenerative arthritis, the panel recommends no change from the PEB determinations as not unfitting.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Post ACL Reconstruction, Right Knee	5299-5257	10%	
Degenerative Arthritis, Right Knee	5299-5259	10%	
Degenerative Arthritis, Left Knee	5299-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161026, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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 Jun 18 ICO XXXXXXXXXXXXXXXXXX	
             (c) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 11 Jun 18 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) 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 20 percent disability rating (increased from 10 percent) effective date of discharge.

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

     c. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 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 USN: 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.
 
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXX
                                  Assistant General Counsel
                                  (Manpower and Reserve Affairs)