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
12 Feb 20

From: To:

Director, Secretary of the Navy Council of Review Boards 
PD-2017-01650

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 22 Feb 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy of 15 October 2019 for appropriate  action.

2.	On 31 January 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no 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.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-01650
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20091019

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Submarine Carry-On Equipment Technician, medically separated for “patellofemoral syndrome right knee” with a disability rating of 10%.

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 - 20090708	VARD - 20100624	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Syndrome Right Knee	5099-5003	10%	Right Patellofemoral Syndrome	5260	10%	20100212	
Pain Disorder	Cat II	
No VA Placement	
Anxiety Disorder	Cat II		
Alcohol Abuse	Cat IV		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Patellofemoral Syndrome Right Knee. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent right knee surgery in November 2008 with lateral release. He was diagnosed with patellofemoral syndrome and despite conservative treatment including Synvisc injections, had continued right knee pain. The 26 May 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic right knee pain.

Physical examination showed a slightly abnormal gait, favoring the right knee. No edema was noted. On testing, there was no laxity or instability. The right knee had generalized patella tenderness and strength was slightly decreased (4/5). Right knee range of motion (ROM) testing showed flexion of 120 degrees (normal 140) and extension of 0 degrees (normal). Painful motion was noted.

At the time of the pain clinic appointment on 6 July 2009, 3 months prior to separation, the CI reported chronic 6-7/10 right knee pain. On examination, the CI wore a knee brace and had a fairly normal gait. He did not favor his right knee when he walked. He had a well healed arthroscopic incision scar and no localized tenderness. He had fairly good ROM and no gross motor deficits in the bilateral lower extremities. The examiner noted the CI’s pain seemed to be out of proportion to the clinical findings and recommended follow-up with mental health providers. At the time of the primary care clinic appointment on 13 July 2009, the CI reported chronic 8/10 right knee pain. Physical examination showed normal right knee ROM and normal strength (5/5).

At the 12 February 2010 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported right knee pain and instability. He stated he had episodes of dislocation or subluxation several times a year but less than monthly. Physical examination showed no evidence of instability or grinding. There was crepitation, abnormal tracking and subpatellar tenderness. Right knee ROM showed flexion of 140 degrees and extension of 0 degrees.  Painful motion was noted.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right knee condition 10%, analogously coded 5003 (arthritis, degenerative). The VA also rated the right knee condition 10%, coded 5260 (leg, limitation of flexion of), based on the C&P examination, citing objective evidence of painful motion.

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). 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). There was therefore no VASRD §4.71a rating higher than the 10% 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 right knee condition.

Contended Category II PEB Conditions. The PEB listed the pain and anxiety disorders as category II conditions, conditions that are related to the primary unfitting condition and contribute to the primary unfitting condition. The panel’s first charge for these Category II conditions is to assess whether any of them can be reasonably justified as separately unfitting for rating consideration. Difficulties with marked anxiety and depressive symptoms related to pain were noted in treatment records beginning in May 2009 in the setting of the MEB for the knee condition being dictated. The initial mental health evaluation on 19 May 2009 noted a complaint of “I am facing discharge due to right knee...I am having stress and problems controlling my anger… I am very emotional.” On mental status examination (MSE) his mood was markedly anxious and dysphoric with congruent affect. There was no suicidal ideation, delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment or other abnormality. Most of the CI’s thoughts centered on being too young to have such orthopedic problems, and the CI appeared to be in a great deal of pain during the interview.  The examiner

stated that psychological test (MMPI-2) “results suggest that he is chronically anxious and depressed.”  The Axis I diagnosis was “Pain Disorder associated with psychological factors.”

The mental health NARSUM addendum dated 2 June 2009, 5 months prior to separation, indicated diagnoses from that day’s evaluation were pain associated with psychological and physical factors, alcohol abuse and anxiety disorder, NOS. The CI had been seen twice for cognitive psychotherapy. The psychiatrist prescribed Trazadone to help him sleep and Celexa to treat his depressive and anxiety symptoms.

The CI reported that dealing with his pain and seeing his future as bleak because of his chronic knee problems had resulted in his feeling depressed, not being able to sleep, feeling anxious, obsessively worrying and abusing alcohol in order to deal with the pain. His depressive condition has waxed and waned in relation to the worsening of his knee pain which had not improved and made doing many of the routine activities of daily living a painful experience. The examiner indicated the CI continued to present as dysphoric and anxious and expressed a sense of hopelessness and helplessness about his chronic knee problem. The MSE revealed that the CI presented as dysphoric, feeling bleak about the future. He denied current suicidal thoughts. There were no indications of a thought disorder. Much of his focus centered around his physical pain and the adverse effects it had on his ability to function. The psychiatrist indicated the CI required psychotherapy and medications. The psychiatrist stated: “This condition alone is so severe that it adversely affects his employability in the civilian world.”

The Category II conditions were not noted on limited duty forms, but were forwarded by the MEB on NAVMED 6100/1. There was no VA mental health claim, mental health examination or rating subsequent to separation. The pain disorder related specifically to the pain from the unfitting/rated right knee condition and was an intertwined diagnosis with the knee. It was appropriately subsumed under the knee condition rating since more than one rating based on the same impairment (knee pain) is prohibited, IAW §4.14 (avoidance of pyramiding). The anxiety disorder did not appear to have any impact on duty performance until the MEB was already underway and was focused predominantly on the knee pain. Therefore, the panel adjudged that the anxiety disorder would not have risen to the level of being referred into the disability evaluation system, and that it was likewise an intertwined diagnosis with the knee which was appropriately subsumed under the knee condition rating since it may have magnified the knee pain disability, but was not reasonably separately unfitting and ratable. Panel members concluded that a preponderance evidence indicates the Category II pain and anxiety disorders were not justified as separately unfitting; given the acute onset during the MEB timeframe and preponderant focus on the painful (unfit and rated) knee condition. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB’s category II determinations for the contended mental health conditions, so no additional disability rating is recommended.

Contended Category IV PEB Condition: Alcohol Abuse. Alcohol abuse is a condition not constituting a disability and was appropriately determined to be a category IV condition by the PEB.  Therefore, no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the right knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended category II pain and anxiety disorders, the panel recommends no change in the PEB adjudications. In the matter of the contended alcohol abuse, the panel recommends no change from the PEB determination as not ratable. 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.