RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00729
BRANCH OF SERVICE:  MARINE CORPS 		 SEPARATION DATE:  20060531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Small Arms Repairman, medically separated for “patellofemoral arthritis” with a contributing condition “left medial femoral condyle osteochondral defect status post oats procedure,” with a disability rating of 10%.

CI CONTENTION:  The CI submitted a lengthy contention for his unfit knee condition.  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 Physical Evaluation Board (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 Veterans Affairs Schedule for Rating Disabilities (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 – 20060403	VARD - 20070924  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellofemoral Arthritis	5299-5003	10%	Left Knee Osteochondral Defect	5099-5014	10%	20070911	
Left Medial Femoral Condyle Osteochondral Defect Status Post Oats Procedure	Cat II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Patellofemoral Arthritis Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had injured his knee and developed chronic pain eventually undergoing left knee arthroscopic surgery in January 2004 for an osteochondral lesion.  Despite rehabilitation attempts, the CI continued to experience pain post-surgery.  Magnetic resonance imaging (MRI) showed the CI had a large medial femoral condyle osteochondral defect (wearing away of cartilage in the knee joint).  He was subsequently taken back to surgery in February 2005 when an OATS procedure was performed [osteoarticular transfer system – moving cartilage from an undamaged area of a joint to a damaged area to affect repair].  At the time of the physical therapy (PT) clinic appointment on 8 July 2005, 5 months after the second surgery and 10 months prior to separation, the CI reported no difficulties, that he was running twice a week for 30 minutes with no swelling or pain.  On examination, he could perform symmetric single leg mini squats and hops and horizontal leaps.  The examiner recorded the CI had met his physical therapy goals and recommend return to full duty.  In September 2005, at an orthopedic post-surgery follow up, the CI reported inability to run more than a mile and pain with stairs and prolonged sitting.  His symptoms were improved post-surgery, but he was “no where near” his prior injury state.  X-rays in September 2005 reported the CI’s condition as “patellofemoral degenerative joint disease (or arthritis), with appropriate postoperative changes for the left medial femoral condyle osteochondral defect.”  Despite ongoing treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  

At the MEB NARSUM examination on 8 September 2005, 7 months after the second surgery and 8 months prior to separation, the examiner noted 5/5 muscle strength and equivalent ligament stability testing.  At a follow-up primary care visit on 25 January 2006, 11 months after the second surgery and 4 months prior to separation, the CI reported being able to do some running, which then caused swelling and pain.  The examiner noted intact ligaments and “not a lot of excess movement to the knee itself.”  A Baker’s cyst [fluid accumulation on the back of the knee] was noted on the left.  The examiner administered a steroid injection to the left knee for pain management.  At the 3 March 2006 examination conducted by this same physician, major knee ligaments and the patellar tendon were noted to be intact and without laxity, although the examiner recorded “some general instability to the knee itself.”  Crepitus was evident with flexion and extension.  There was also mild effusion and some pain noted throughout ROM testing.  A second steroid injection was administered to the left knee for pain control.  At the VA Compensation and Pension (C&P) examination on 11 September 2007, 15 months after separation, the CI reported diminished ability to participate in activities with his children due to his left knee.  There were no limitations on standing or walking reported by the CI.  Physical exam showed a normal gait.  Pain was present on ROM testing.  The examiner noted no significant effects attributable to the CI’s left knee on general occupational function but there were mild effects on recreation and doing chores and moderate effects on exercise and playing sports.  

The Board directed its attention to its rating recommendation based on the above evidence.  The Formal PEB rated the left knee condition 10%, coded analogously 5299-5003 (degenerative arthritis) citing radiographic evidence and functional loss.  The VA also rated the left knee condition 10%, coded analogously 5099-5014 (osteomalacia), citing for painful or limited motion of a major joint.  There was no limitation of motion which attained a minimum 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) as adjudicated by the PEB.  There was also no frequent locking with effusions or any indication of dislocated meniscus or loose body (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was 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.  The Board noted that the PEB’s documentation of the Category II condition “left medial femoral condyle osteochondral defect status post OATS procedure” was properly subsumed under the rating for the CI’s patellofemoral arthritis of his left knee.  To rate this Category II condition as a separate unfit condition would be medically inappropriate and would be in violation of VASRD §4.14 (avoidance of pyramiding).  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 CI’s patellofemoral arthritis of the left knee condition.  

BOARD FINDINGS:  In the matter of the patellofemoral arthritis (left knee) 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 20140205, 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 11 Mar 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:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC