RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00411
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20070814

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Rifleman) medically separated for status post left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “old disruption of anterior cruciate ligament” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded two other conditions (multiple and unspecified open wound of lower limb and multiple and unspecified open wound of upper limb, without mention of complication) for PEB adjudication.  The Informal PEB adjudicated “status post left ACL reconstruction” as unfitting, rated 10%.  The remaining condition (… residual foreign bodies of the left elbow, hip and hand) was determined to be Category III, not separately unfitting not contributing to the unfitting condition.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his condition(s) by the VA.  His complete submission is at Exhibit A. He further contends that he was not evaluated for his back condition.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB - Dated 20070516	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Left ACL Reconstruction	5299-5003	10%	Left Knee Residuals ACL Repair	5261	10%	20071106	
… Residual
Foreign Bodies of Left Elbow, Hip and Hand	Category III	Left Hand Residuals Fragment Wound	7899-8515	10%		
		Left Hip Condition	7805	0%		
		Left Leg Condition	7805	0%		
		Left Arm Residuals Fragment Wound, Elbow	7805	0%		
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 8	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20071115 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Status Post Left ACL Reconstruction Condition.  A service treatment record (STR) note dated 11 February 2006 indicated the CI complained of a painful left knee injury for 3 weeks when his knee gave out while wrestling.  He had full flexion with mild pain.  There was no swelling or edema, but there was mild tenderness to palpation of the distal patella (kneecap) and no instability.  Treatment with Celebrex (celecoxib, a nonsteroidal anti-inflammatory drug (NSAID)) and naproxen (an NSAID) was instituted.  An orthopedic note in June 2006 mentioned a left knee valgus injury in 2004 during deployment with symptoms of minimal pain, giving way and feeling wobbly, but without locking, catching, or swelling.  Examination demonstrated a full range-of-motion (ROM) and a positive Lachman 2B (to test for instability), which raised the diagnosis of knee sprain of the anterior cruciate ligament.  In July 2006 the CI noted left knee instability and giving way without locking or catching and a left knee anterior cruciate ligament (ACL) reconstruction was recommended.  X-rays were unremarkable and an MRI confirmed an ACL tear and a possible medial meniscus tear.  Despite extensive physical therapy and activity modification, the CI was still symptomatic.  On 25 July 2006, the CI underwent arthroscopic-assisted left knee ACL reconstruction with a hamstring autograft.  The medial and lateral menisci were normal as was the posterior cruciate ligament.  One week postoperatively there was a localized effusion and the ROM was 0-75 degrees; physical therapy was then instituted. On examination on 25 August 2006 the left knee ROM was 0 to 135 degrees without tenderness about the knee and without instability; however, there was quadriceps atrophy.  Three weeks later the ROM was 140 degrees on one exam and 0 to 135 degrees on another and a hinged neoprene brace was being used.  In November 2006 the CI indicated the “knee works now,” not giving out/twisting and for the most part pain free.  He noted “if not for the hip/shrapnel I’d feel ready to run.”  Ambulation was normal although there was moderate left quadriceps atrophy.

A Limited Duty Medical Board dated 29 November 2004 was issued with limitations of no field training, no group physical training, and no deployment, but the CI could train at his own pace.  The MEB narrative summary (NARSUM) dated 14 March 2007 noted the CI complained of persistent left knee pain status post left ACL reconstruction.  Examination revealed a full ROM of the left knee, which was stable to varus-valgus stress testing, a negative dial (to diagnose posterolateral instability), a negative posterior drawer test, and a 1A Lachman; and there was no mediolateral joint line tenderness.  Pending the outcome of the PEB he was not to engage in any physical readiness training, running, heavy lifting, prolonged walking, standing, crawling, or assignment to any area where his unsteady gait may pose a danger to himself or others.  The non-medical assessment dated 28 March 2007 indicated that the commanding officer’s only concern was that the CI receive the proper medical care prior to being released from active duty and that his medical condition was fully documented and treated prior to his release in order to afford him the opportunity for a healthy life outside the military.  At the MEB examination dated 30 April 2007, the CI reported his medical concerns with the MEB examiner and noted he had persistent weakness/instability of the left knee S/P reconstruction of the ACL with a hamstring graft.  The MEB examiner noted left ACL repair symptoms, an MS [motor/sensory] deficit in the left hamstring, and postop changes of the left calf.   

At the VA Compensation and Pension (C&P) examination dated 6 November 2007, performed approximately 3 months after separation, the CI reported his left knee was injured by a bomb blast on 24 May 2004 and shrapnel was in the left knee.  In October 2005 he noted a left knee snap.  An MRI was performed and there was a torn ACL of the left knee, which was subsequently reconstructed in July 2006.  However, his hamstring muscle hurt because of shrapnel in it and he took naproxen as needed.  Examination revealed flexion of 0 to 130 degrees with pain beginning at 0 degrees.  There was no limitation of motion on repetitive use of either flexion or extension.  X-rays performed in November 2007 showed no osteoarthritic changes; however, there was a staple in the upper end of the left tibia due to the previous ACL repair.  The examiner’s final diagnosis was left knee strain S/P ACL repair surgery.  

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Knee ROM
(Degrees)	Ortho ~13 Mo. Pre-Sep	Ortho ~13 Mo. Pre-Sep	PT ~12 Mo. Pre-Sep	
Flexion (140 Normal)	135	75	95	
Extension (0 Normal)	0	0	0	
Comment	(+) Lachman 2B, (+) pivot shift, stable varus/valgus	Localized moderate effusion; subjective instability	Significant effusion and soft tissue thickening about the patella	
§4.71a Rating	10%	0%	0%	

Left Knee ROM
(Degrees)	Ortho ~12 Mo. Pre-Sep	PT ~11 Mo. Pre-Sep	NARSUM ~5 Mo. Pre-Sep	
Flexion (140 Normal)	135	140	FROM	
Extension (0 Normal)	0	0		
Comment	Localized minimal effusion, no instability, quadriceps atrophy	Wearing hinged neoprene race, left quadriceps atrophy	No laxity; negative mediolateral joint line tenderness	
§4.71a Rating	0%	0%	PEB 10%	

Left Knee ROM
(Degrees)	VA C&P ~3 Mo. Post-Sep	
Flexion (140 Normal)	130	
Extension (0 Normal)	0	
Comment	Pain began at 0 degrees; DeLuca negative	
§4.71a Rating	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5299-5003 (degenerative arthritis) for the Category I status post left ACL reconstruction condition.  The VA assigned a 10% rating using code 5261 (Leg, limitation of extension) for left knee residuals ACL repair.  The Board sought a route to a higher rating, but was unable to find one in the absence of ankylosis, recurrent subluxation or lateral instability, meniscal tears, impairment of the tibia and fibula, or genu recurvatum.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the Category I status post ACL reconstruction condition.  

Contended PEB Conditions-Status Post IED Blast with Residual Foreign Bodies of the Left Elbow, Hip and Hand.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Category III residual foreign bodies of the left elbow, hip and hand conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The residual foreign bodies of the left elbow, hip and hand conditions were not explicitly identified in the LIMDU or implicated in the non-medical assessment.

The CI complained of shrapnel in his left hip, left elbow and left hand status post an IED blast on 26 May 2004.  He underwent a number of surgeries to remove superficial shrapnel, but fragments persisted.  The shrapnel of his posterior left elbow was not palpable and was not tender.  He did have a palpable foreign body at the base of his 2nd metacarpal of his left hand that was non-tender.  He had full ROM of the elbows and wrist with full strength.  His left hip had no palpable foreign bodies and he had a full ROM of the hip.  At the VA C&P examination, the CI noted he had pain in the left elbow, which hurt when touched.  He was unable to do strenuous things such as lift weights.  X-rays showed a foreign body at the posterior midline of the elbow, just posterior to the proximal ulna, which was clearly extraarticular.  Pelvic films showed two views of shrapnel, one on the posterior aspect along the femoral neck and one more anteriorly and medially in the proximal thigh.  Squatting or forward bending forward caused pain in the hip. There was less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight bearing.  

X-rays of the hand showed a deformed body at the proximal aspect of the left 2nd metacarpal.  The VA assigned a 10% rating for the 2nd metacarpal shrapnel for incomplete paralysis of hand movements, which was mild, based on paresthesia on the dorsum of the left index finger and left thumb status post left hand shrapnel wound injury and mild pain in the dorsum of the left ring finger with scattered scars of the dorsum of the left hand.  

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the residual foreign bodies of the left elbow, hip and hand Category III conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the status post left ACL reconstruction condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended residual foreign bodies of the left elbow, hip and hand conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140113, 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) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 21 Dec 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXXX former USMC  
- XXXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXXX former USMC 

						  XXXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)