RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXX	CASE: PD-2017-01153
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20090615

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Individual GWOT IA/LO Multi-National Force member, medically separated) for “right knee patellofemoral joint instability status post (s/p) Fulkerson Procedure with residual pain” and “left patellofemoral joint instability s/p Fulkerson Procedure,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: “VA rated me at 50% for same condition the Navy rated me at 20%.” 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 - 20090305	VARD - 20090810	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Patellofemoral Instability…	
5099-5003	
10%	Chronic Patellar Instability, S/P Arthroscopy and Fulkerson, Right Knee	5257	10%	20090427	
			Residuals, Recurrent Dislocations, Right Knee	5260	10%	20090427	
Chronic Joint Pain	Cat II					

Left Patellofemoral Joint Instability…	
5099-5003	
10%	Chronic Patellar Instability, S/P Arthroscopy and Fulkerson, Left Knee	5257	10%	20090427	
			Degenerative Arthritis, S/P Recurrent Dislocations, Left Knee	5260-
5003	10%	20090427	
NO PEB Placement	Residual Surgical Scarring, Bilateral Knees	7804	10%	20090427	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Right Knee ... According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right knee condition began in April 2008 when the CI complained of right patellar instability and pain associated with playing basketball. A CT scan of the bilateral knees showed subluxation of the patellar, left greater than right. In October 2008, the CI underwent a right knee Fulkerson procedure with lateral release. No further episodes of instability or subluxation were reported.

The 5 February 2009 MEB NARSUM examination, 4 months prior to separation, noted complaints of left greater than right patellofemoral pain with limited activity. Physical examination of both knees revealed “full symmetric range of motion” (ROM) showing 3 degrees hyperextension (normal 0) and flexion at 130 degrees (normal 140). There was no patellar instability on ROM. The medial and lateral patellar glide was normal and there was no abnormal patellar tilt. Patellar crepitus was positive, left greater than right. There was pain with patellar compression and quadriceps inhibition with patellar compression, left greater than right. No effusion or edema was noted. Both knees were stable to ligamentous knee examination with normal Lachman, anterior and posterior drawer, and varus and valgus at 0 and 30 degrees. During the MEB examination (recorded on DD Forms 2807-1 and 2808) 4 days later, the CI reported bilateral residual pain and buckling. Physical examination documented mild diffuse swelling of the anterior aspect of the right and left patella.

At the 27 April 2009 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported bilateral knee pain exacerbated by physical activity and relieved by rest. Physical examination showed tenderness in both knees in the anterior aspect over the patella in the midline. Crepitus was noted bilaterally. Ligaments were stable. ROM showed right knee flexion of 130 degrees and left knee flexion of 125 degrees with pain at the endpoints. Both knees had extension of 0 degrees.  There was no increased disability on repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right knee condition 10%, analogously coded 5099-5003 (degenerative arthritis). The PEB related chronic joint pain to the right knee condition as a Category II condition, that contributed to the primary unfitting condition but was not separately ratable. In this case the Category II condition was an aspect of the same disability and not a separately unfitting condition or separately ratable IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited). The VA rated the right knee condition 10%, coded 5260 (leg, limitation of flexion), based on the C&P examination, citing painful, limited flexion on examination. The VA additionally rated the right knee 10%, coded 5257 (knee, other impairment), citing chronic instability.

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for the right knee. However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45), for the right knee. 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). In considering support for a higher rating, the panel noted the PEB’s adjudication that allows for panel consideration of dual coding for pain and instability. Although there were complaints of knee buckling (instability), there was no objective evidence of post-surgical knee instability for additional (dual) rating for instability under code 5257. The panel concluded there was insufficient evidence of ligament instability to support dual coding under 5003 and 5257. There was therefore no higher rating than the 10% adjudicated by the PEB available under any applicable VASRD 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 right knee condition.

Left Knee Patellofemoral Instability …. According to the STR and MEB NARSUM, the CI’s left knee patellar condition began in 2005 when he CI sustained a fall resulting in a left patellar dislocation. Subsequently, the CI had recurrent episodes of left patellar instability and dislocation with pain. A CT scan of the bilateral knees showed subluxation of the patellar, left greater than right preoperatively. In April 2008, the CI underwent a left knee Fulkerson procedure with lateral release secondary to left patellar instability and pain. A Grade II to III chondral fissuring and degenerative changes were noted. No further episodes of instability were reported. There was no further improvement with conservative treatment.

The examinations and evidence for the left knee were included along with the right knee analysis above. The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left knee condition 10%, analogously coded 5099-5003. The VA also rated the left knee conditions 10%, coded 5260-5003 based on the C&P examination, citing painful, limited flexion on examination. The VA additionally rated the left knee 10%, coded 5257, citing chronic instability.

The panel noted there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for the left knee. However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45), for the left knee. The panel considered other VASRD knee and analogous codes, but all were less applicable and not advantageous for rating. As noted with the right knee, when considering support for a higher rating, the panel noted the PEB’s adjudication allows for panel consideration of dual coding for pain and instability. Although there were complaints of knee buckling (instability), there was no objective evidence of post-surgical knee instability for additional (dual) rating for instability under code 5257. The panel concluded there was insufficient evidence of ligament instability to support dual coding under 5003 and 5257. There was therefore no higher rating than the 10% adjudicated by the PEB available under any applicable VASRD 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 left knee condition.

BOARD FINDINGS: In the matter of the right and left knee patellofemoral instability status post Fulkerson procedure with residual pain and IAW VASRD §4.71, the panel recommends no change in the PEB adjudications. 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.

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY  REFER  TO:
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY  BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 21 Apr 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate  action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.