RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:XXXXXXXXXXXXXXXXX	CASE:  PD-2017	-0498	2
BRANCH OF SERVICE:  NAVY	SEPARATION DATE: 20050725
SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Engineman, medically separated for “proximal tibial osteotomy on the right knee” with a disability rating of 10%.
CI CONTENTION: Condition has worsened and affecting ability to work. 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 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 – 20050421	VARD – 20051117 / 20060325	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Proximal Tibial Osteotomy Right Knee	5299-5003	10%	Degenerative Changes, Postoperative Right Knee Strain...	5010-5260	20%	20050503
20060121	
Right Greater than Left Knee Pain	Cat II	Left Knee Strain	5299-5260	10%		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Right Knee Tibial Osteotomy. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent right knee surgery (wedge proximal tibial osteotomy) on 18 August 2003, with subsequent hardware removal on 1 September 2004. The surgery was to correct congenital tibia vara (abnormal joint tilt) and there was no ligamental or meniscal pathology or history of trauma. Post-operative provider entries documented restoration of normal or near-normal range of motion (ROM), and no persistent effusion, impingement (locking),  or  instability.  Gait  was  noted  to  improve  post-operatively  with  one  entry  on   10 November 2004 (2+ months after hardware removal) recording a “slight” gait disturbance, and an entry a few weeks later indicating a normal gait. There was no reported use of a brace (other than post-op) or assistive device.

During the 17 February 2005 MEB NARSUM examination, 5 months prior to separation, the CI complained of persistent nonspecific right knee pain (no reported weakness or instability) that

had not responded adequately to surgery and prevented resumption of full duties. Her limited duty board (LIMDU) prohibited ladders and shipboard duties. The physical examination recorded tenderness but a normal gait, and no effusion or instability. Measured ROM revealed flexion to 135 degrees (normal 140) and extension to 0 degrees (normal). There was no documentation of injury or other exacerbation in the interval between the NARSUM and separation.

At the 3 May 2005 VA Compensation and Pension (C&P) general examination, 2 months before separation, the CI reported daily right knee pain rated at 8/10 with intermittent “collapse” of the knee, “weakness, lack of endurance and fatigue.” The only specified functional limitation was the inability to squat. The physical examination recorded an antalgic gait with reported use of “crutches or a cane,” but no tenderness or effusion. A “varus stress test,” and McMurray’s signs (implying mechanical impingement) were positive, and the examiner stated that the knee became “very weak” (albeit graded 4/5) with “repetitive activity.” Measured ROM showed flexion to 130 degrees and extension to 0 degrees.

At the 21 January 2006 C&P joint examination, 6 months after separation, the CI reported nonspecific right knee pain, with “no instability,” that was aggravated by prolonged standing and walking. The examiner opined that it had no effect on her occupation (student) or daily activities. The physical examination recorded a “slight antalgic gait favoring the right knee” without assistive device, effusion, or instability, and no note of tenderness, impingement, or weakness. Measured ROM revealed flexion to 130 degrees and extension to0 degrees, specifying the absence of pain or discomfort with motion or any ROM degradation with repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right knee condition 10%, coded 5299-5003 (analogous to degenerative arthritis [correct prefix is 5099]). An original VA rating decision (date charted above) conferred a 20% rating for the right knee, coded 5010-5260 (traumatic arthritis rated for limitation of leg flexion), based on the pre-separation C&P examination. That VARD justified a 20% rating for the “disability picture” based on the weakness and functional impairment reflected in the C&P examination, although those criteria are not captured by the applied code. The original VARD deferred a finalized rating pending the post-separation joint examination. The follow-up VARD as charted above, based on both C&P examinations, continued the same code and rating because of “sustained improvement has not been definitively established.” Panel members agreed that there was no compensable limitation of flexion or extension (5260 or 5261); no 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 that those codes. The panel also considered analogous rating of overall functional impairment under code 5299-5262 (tibia and fibula, impairment of) which offers higher ratings for contiguous knee disability (20% for “moderate” and 30% for “severe”), but ultimately agreed, however, that this was not justified. The severity of functional impairment noted in the pre-separation C&P examination was inconsistent with that reported in STR provider notes, the NARSUM, and the post-separation C&P examination. The preponderance of evidence indicated that the disability at separation (normal or improving gait, good mobility, and limitation only of more demanding activities) was not reasonably characterized as moderate. There were no other criteria in evidence to support a rating higher than 10% under any applicable VASRD §4.71a code. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.

Left Knee Pain. Members agreed that the PEB’s Category II (conditions that contribute to the unfitting condition but are not separately ratable) diagnosis incorporated less severe left knee pain, although the right knee pain was intrinsic to the rated condition and not subject to additional rating. The left knee pain was subject to panel consideration as separately unfitting,

and possibly subject to additional rating, accepting the PEB acknowledgement that it was implicated as unfitting.

There was an atraumatic onset of left knee pain in 2002 soon after the right knee became symptomatic. Left knee pain was acknowledged in some earlier STR entries, always less severe than the right, but subsequent encounters leading up to the right knee surgery did not note any left knee pain. The same was true after the surgery until an orthopedic entry of 7 December 2004 (3 months after the right knee hardware removal) which noted that the CI was also starting to complain of left knee pain. The NARSUM and both C&P examiners documented the presence of less severe left knee pain. All STR provider, NARSUM, and VA examinations of the left knee documented normal ROM with no abnormal findings other than intermittent tenderness and/or painful motion. The commander’s non-medical assessment implicated the right knee only, and the LIMDU was for the right knee only. The STR indicated that the MEB referral was for the right knee only. All of the performance-based evidence attributed gait disturbance and other functional limitations to the right knee, although some contribution from the left knee could not be excluded. The panel ultimately agreed that the preponderance of evidence indicated that the left knee was not unfitting, either separately or by combined effect. After due deliberation, considering all the evidence and with deference to reasonable doubt, the panel concluded that there was insufficient cause to recommend a change in the PEB’s Category II determination for the left knee pain.

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 left knee pain, the panel recommends no change from the PEB determination as Category II. 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:

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

IN REPLY REFER TO:
1850
CORB: 003
10 Sep20

From: Director, Secretary of the Navy Council of Review Boards To:

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) Ref:	(a) DoDI 6040.44
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy on 13 Aug 2020 for appropriate action.

2.	On 27 August 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.