RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00613
BRANCH OF SERVICE:  MARINE CORPS		SEPARATION DATE:  20070109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Motor Transportation Maintenance Chief, medically separated by the Informal Physical Evaluation Board for “S/P laceration flexor pollicis longus tendon with repair” and “right patellofemoral pain syndrome, posttraumatic,” with a disability rating of 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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:

SERVICE PEB - 20061130	VARD – 20070627	
Condition	Code	Rating	Condition	Code	Rating	Exam	
S/P Laceration Flexor Pollicis Longus Tendon with Repair	5307	10%	Right Hand Condition	5208	NSC	20070330	
Right Patellofemoral Pain Syndrome, Posttraumatic	5299-5003	10%	Right Knee Patellofemoral Syndrome	5299-5257	10%		
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Right Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in March 2005 after he fell down a flight of stairs.  He improved with conservative treatment and was subsequently deployed, but the anterior knee pain worsened during deployment.  Right knee X-rays noted no fractures and magnetic resonance imaging on 5 May 2005 showed chondromalacia patella (CMP-thinning of the patellar cartilage) and was interpreted by the sports medicine specialist as otherwise negative.  Despite additional treatment with activity modification, physical therapy, and joint injections, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.

At the MEB NARSUM exam on 3 October 2006, performed 3 months before separation, the CI reported anterior right knee pain, aggravated by sitting, squatting, and weight bearing activities.  He was not taking any medications for the knee condition.  The physical exam showed right knee range-of-motion (ROM) of flexion 130 degrees (normal 140) and extension 0 degrees (normal 0).  There was a positive patellar grind test and patellofemoral (PF) crepitus.  Muscle bulk and strength of the right lower extremity was normal.  The most recent X-rays were noted to demonstrate “mild degenerative changes” of the PF joint, with no other abnormalities.

At the VA Compensation and Pension (C&P) examination on 30 March 2007, performed 3 months after separation, the CI reported intermittent right knee pain treated with non-steroidal anti-inflammatory medications.  Physical exam showed a normal gait.  There was no joint swelling, effusion, tenderness or laxity noted.  Right knee ROM was flexion 140 degrees and extension 0 degrees, with pain occurring at 115 degrees flexion.   Exam of the lower extremities was normal.

The Board 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).  The VA rated the right knee condition 10%, coded 5299-5257, (analogous to other knee impairment).  The Board agreed that the evidence supports a 10% rating coded according to 5003 rating criteria for painful motion of a single major joint with imaging evidence of degenerative changes as adjudicated by the PEB.  The Board reviewed to see if a higher rating was supported with any applicable code, but there was no evidence in record of limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261); ligamentous instability or laxity (5257); frequent locking with effusions or indication of meniscus or semilunar cartilage injury (5258); or, surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was also no fracture, non-union, 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 is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 right knee condition.

Right Thumb Condition.  According to STR and the MEB orthopedic addendum the CI lacerated his right dominant thumb between the base of the thumb and the interphalangeal joint while removing broken glass from the dishwasher on 25 April 2006.  He lacerated the tendon that flexes the thumb (flexor pollicus longus) and underwent surgery for tendon repair the next day.  The CI participated in therapy for months after surgery and regained significant thumb ROM, but there was decreased strength and ROM compared to the unaffected thumb.  An occupational therapy note dated 13 November 2006 indicated that the weakness and limited ROM of the CI’s thumb prevented performance of the full duties of his MOS or firing a weapon and an MEB was initiated.  

The MEB orthopedic evaluation on 16 November 2006, 2 months before separation, noted that there had been no improvement in thumb ROM in the past two months.  On exam there was a well healed scar on the thumb, with intact sensation.  There was limited ROM of the interphalangeal (IP) joint (30 degrees) compared to the left thumb (60 degrees).  Overall grip strength of the right hand was 80% of the left (this measure was noted to not expected to be significantly impacted by thumb injury), and right pinch strength (noted to be directly affected by the thumb injury), was 61% of the left.  Further intervention (tenolysis) was discussed, but due to possible complications of the procedure, the CI declined.

The VA Compensation and Pension (C&P) examination on 30 March 2007, performed 2 months after separation, noted “some motion loss” at the IP joint with “mild” grip strength loss, without flare-ups, and no limitation of function due to the scar.  Physical exam noted flexion and extension of the thump IP joint, without painful motion.  There was no gap on opposition of the thumb and fingers.  Right upper extremity reflexes and sensation were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thumb condition 10%, coded 5307 (muscle injuries, Group VII-thumb flexors), for “moderate” muscle injury.  The VA denied service-connection of the right hand [thumb] condition, citing that although there was a record of “treatment in service for right hand condition, no permanent residual or chronic disability subject to service-connection is shown by the STR or demonstrated by evidence following service.”  

The Board first reviewed the rating criteria of 5307 which are subjective, with a 0% rating for “slight”, 10% rating for “moderate”, 30% for “moderately severe”, and 40% for “severe” muscle injury of the dominant upper extremity.  The Board considered that according to VASRD §4.56 (evaluation of muscle disabilities) the discrimination between the 5307 rating levels depends upon the type of injury, presence or absence of one or more of the cardinal sign or symptoms of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” and the objective findings on exam.  The Board agreed that the evidence supports a 10% rating IAW VASRD §4.73 (muscle injuries) for moderate muscle injury based upon the presence of injury due to a laceration with the presence of a scar, decreased thumb ROM, and weakness on exam.  The Board reviewed to see if the next higher evaluation of 30% was supported, but judged that mechanism of injury, which was a deep, but simple laceration with a sharp object, with mild decreased ROM and limited weakness did not support characterizing the disability due to the thumb injury as moderately severe.  The Board also considered if coding and rating IAW VASRD §4.71a (musculoskeletal conditions) provided a higher rating, but there was no evidence of unfavorable thumb ankylosis (5224) or sufficiently limited thumb ROM (5228) to support a 20% rating with either of the two applicable codes.  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 thumb condition.

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right thumb condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

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 20140119, 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 16 Feb 16

      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:

- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USN   
- XXXXXXXXXXXXXXXXXXXX, former USN 

			XXXXXXXXXXXXXXXXXXXX	     				  	Assistant General Counsel
			(Manpower & Reserve Affairs)