RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXX			BRANCH OF SERVICE:  Marine Corps 
CASE NUMBER:  PD0900551			SEPARATION DATE:  20031215
BOARD DATE:  20110107

SUMMARY OF CASE:  Data extracted from available records reflects that this covered individual (CI) was an active duty Corporal/E-4 (MOS 6042, Individual Materiel Readiness List manager) medically separated from the Marine Corps in December 2003 after 3 years of military service.  The medical basis for separation was Persistent Left Knee Pain, Status Post Multiple Arthroscopic Procedures.  The CI developed left knee pain in May 2000, during basic training.  Her knee was treated with conservative measures, and she also underwent multiple surgical procedures.  She did not respond adequately to treatment.  In April 2003, following her third period of Limited Duty (LIMDU) it was determined that she was unable to fulfill the requirements of an active duty Marine to include prolonged standing, marching, running, kneeling, crawling and climbing.  The CI was referred to a Physical Evaluation Board (PEB) and was found unfit for continued military service, due to the left knee condition.  On 15 Oct 03, the CI accepted the PEB findings, and waived her right to a formal hearing.  Two months later (15 Dec 03) she was separated with 10% disability using the Veterans Administration Schedule for Rating Disabilities (VASRD) and applicable Navy and Department of Defense regulations.

CI’s CONTENTION:  The CI elaborates no specific contention in Block 3 of the DD Form 294.  

RATING COMPARISON:

Service IPEB  	VA (2 mo. before Separation)	
Condition	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Left Knee Pain, s/p Multiple Arthroscopic Procedures 	5299-5003	10%	20031001	Left knee pain	5259	10%	20031023	20031216	
No PEB Entry for Hip pain		Left hip pain	5299-5255	10%	20031023	20031216	
No PEB Entry for Sinusitis		Sinusitis	6510	0%	20031023	20031216	
No PEB Entry for Asthma		Bronchial Asthma	6602	0%	20031023	20031216	
No PEB Entry for Migraines		Migraine Headaches	8100	0%	20031023	20031216	
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions):    
20%  from 20031216	

ANALYSIS SUMMARY:
Left Knee Pain  The CI developed left knee pain in basic training (May 2000) after a 10 mile road march.  Examination of the knee at that time showed some edema and medial joint line tenderness, but no ligamentous instability.  Radiographs were normal.  The CI was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and rest.  However, symptoms worsened after a 3 mile run in June 2000.  Multiple visits for treatment and evaluation ensued.  Her left knee pain failed to resolve with rest, crutches and nonsteroidal medications.  Dr. W. examined the CI on 9 July 2000, and stated that “pain is out of proportion to the findings.”  The CI underwent physical therapy (PT) beginning in August 2000.  After PT she was able to return to running.  However, she slipped on a rock on 11 Dec 00 and started having left knee pain again.  Examination at that time showed some ecchymosis, but no instability.  Magnetic Resonance Imaging (MRI) on 20 Dec 00 was normal.  A Limited Duty (LIMDU) Board was conducted on 23 Jan 01, with the limitation of “no impact physical training.”  The CI was evaluated in the Orthopedic Clinic at Camp LeJeune by Dr. V.  He diagnosed a chronic plica in the left knee.   In March 2001, Dr. V. injected the plica with corticosteroid.  A second MRI (April 2001) was essentially normal, except for patellar plica and some minimal patello-femoral joint inflammation.  Dr. V. performed arthroscopic plica excision in July 2001.  Post-operatively the CI was treated with PT and her knee pain improved 50%.  A second period of LIMDU was granted, to allow for rehabilitation after surgery.  However the CI continued to have pain and inability to perform impact activities.  She was referred to Orthopedics at the University of North Carolina.  The CI underwent repeat arthroscopy (August 2002) for removal of recurrent plica and scar tissue.  A third LIMDU Board was completed in September 2002.  She received several corticosteroid injections and PT, but still had pain.  A third arthroscopy was performed in March 2003, but the CI did not improve and a Medical Evaluation Board (MEB) was initiated.  At her MEB exam (18 Apr 03), left knee flexion was 130⁰ (normal knee flexion is 140⁰) with trace effusion, but no instability.  Due to her failure to improve after three periods of LIMDU and three arthroscopic procedures, it was determined that the CI did not meet USMC retention standards and she was referred to the Physical Evaluation Board (PEB).  The PEB found the CI unfit for continued military service.  A VA Compensation and Pension (C&P) evaluation on 23 Oct 03 found her left knee flexion range-of-motion (ROM) to be 120⁰.  There was some crepitus and a positive patellar compression test, but no joint instability.  As mentioned above, two goniometric range-of-motion (ROM) evaluations were in evidence, which the Board weighed in arriving at its rating recommendation.  Both of these exams occurred prior to separation from service, and are summarized in the chart below.

Left Knee	Separation Date: 20031215	
Goniometric ROM	MEB - 20030418	VA C&P - 20031023	
Flexion  (140⁰ is normal)	130⁰	120⁰ 	
Extension  (0⁰ is normal)	0⁰	0⁰	
§4.71a Rating	0%	0%	

The Board evaluated all evidentiary information available.  At the time of separation from service, the CI was experiencing chronic, persistent left knee pain, with some limitation of motion.  The ROM limitation did not meet VASRD criteria for a disability percentage (based upon Knee and Leg codes, 5260 through 5261).  However, IAW VASRD §4.71, when limitation of motion of a specific involved major joint is noncompensable under the appropriate diagnostic code, a rating of 10% is appropriate if there is satisfactory evidence of painful motion.  After due deliberation, and careful consideration of all available evidence, the Board unanimously recommends a separation rating of 10% for chronic, persistent left knee pain.  

Left Hip Pain – The CI developed Left hip pain (March 2000) during basic training.  Radiographs showed an irregularity of the femoral neck which raised the possibility of stress fracture.  However, subsequent bone scan (4 Apr 00) was normal, with no evidence of stress fracture.  Therefore, fracture of the femoral neck was essentially ruled out.  By 5 Apr 00 she was pain-free with normal gait, and she returned to full duty.  The CI’s hip pain recurred in September 2000 and August 2001.  Both episodes were diagnosed as muscle strain, and the CI was returned to duty.  In March 2002 the CI fell out of bed, and bruised her pelvis just above the left hip.  This was treated with ice, stretching and NSAIDs.  Review of the Disability Evaluation System (DES) file reveals that left hip pain is not mentioned in the MEB Narrative Summary or the Commander’s statement.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of Left hip pain as an unfitting condition for separation rating.  

Migraine Headaches – On 9 Feb 01 the CI developed a headache with associated photophobia, phonophobia, nausea and vomiting.  This was treated with Toradol and Imitrex. A Computed Tomography (CT) scan of the head on 14 Feb 01 was normal.  Two days later she was treated for another headache episode.  Over the next two months she began having recurring headaches (2 or 3 times per week) and the pain was relieved with Midrin.  Propranolol was given for headache prophylaxis.  A Neurology consult (18 Jun 01) noted that the CI had been having a history of headaches for at least two years.  Review of the Treatment Record reveals that the headaches gave her a great deal of trouble during 2001, but then they improved.  There was apparently just one treatment visit for headaches in 2002 (30 Dec 02), and one treatment visit in 2003 (24 Sep 03).  The Board noted that there is insufficient evidence to support the contention that, at the time of separation, the headache condition rendered her unfit to be a U.S. Marine.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of Migraine Headaches as an unfitting condition for separation rating.  

History of Other Conditions documented in the DES file – Asthma was also discussed and considered by the Board. There is no clearly documented evidence that this condition caused a significant adverse effect on the performance of required military duties.  Asthma is judged by the Board to be not unfitting at the time of separation, and is not relevant for disability rating.  The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

History of Other Conditions (not documented in DES file) – Sinusitis was also noted by the Board.  There is no evidence that this condition was a matter of record in the DES package.  Therefore, sinusitis is judged to be outside the scope of this Board. 

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  

In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.

In the matter of the Left hip pain, Headaches, Asthma, or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation. 

Sinusitis, rated by the VA, was not a matter of record in the Disability Evaluation System (DES) package and is therefore outside the scope of the Board.  The CI retains the right to request her service Board for Correction of Naval Records (BCNR) to consider adding this condition as unfitting.

RECOMMENDATION:  The Board therefore recommends that there be no re-characterization of the CI’s disability and separation determination.

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain	5299-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090911, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                             		

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL
                                  	OF REVIEW BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
    ICO XXXXX, FORMER USMC, XXX XX XXXX

Ref:   (a) DoDI 6040.44
             (b) PDBR ltr dtd 24 Jan 11

      I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review that Mr. XXXX records not be corrected to reflect a change in either his characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board.