RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00821
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20081030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Machine Gunner, medically separated for a knee condition.  The knee could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The “pain in joint involving lower leg,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB adjudicated “chronic anterior knee pain right” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION: The CI writes: “The condition (R Knee) for which I was separated has been linked to multiple other problems for which I am rated by the VA.  These conditions were evaluated and diagnosed prior to separation.  My evaluation of service connected disabilities was conducted in August 2008 with my separation being in October 2008.”  

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 20080916	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Anterior Knee Pain Right	5099-5003	10%	Right Knee Patellofemoral Syndrome	5260-5024	10%	20080910	
Other x 0 (Not In Scope)	Other x 10	
RATING:  10%	RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20081107 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Right Anterior Knee Pain.  The earliest note in the service treatment record (STR) dated 22 May 2006 indicated the CI had pain of the right knee for 8 weeks, which was increasing.  He was unsure whether he had slightly twisted it [going] down stairs, but it did not start hurting until 3 days later.  He had no prior trauma/knee injury.  In November 2006, the CI stated his right knee had been painful since boot camp 9 months earlier and it swelled up after engaging in physical activity.  On examination he had VMO (vastus medialis oblique muscle) atrophy; the right hamstrings were tighter than the left; and he had a positive patellar grind test without instability.  The assessment was patellofemoral pain syndrome (PFPS) and treatment consisted of Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), ice and isotonic exercises.  In December 2006 he complained of swelling and pain of the right knee for 3 weeks.  His range-of-motion (ROM) was full with pain and he was referred to sports medicine for follow-up.  In December 2006 the sports medicine examiner noted the CI’s exam had some features of PFPS and tightness in the muscles with some suggestion of meniscal pathology especially with a history of two twisting injuries.  An MRI dated 5 January 2007 demonstrated localized grade 2-3 patella chondromalacia, a minimal degenerative Grade 2 signal of the posterior horn of the medial meniscus without evidence of a tear, and normal cruciate and collateral ligaments.  The CI was seen in follow-up in November 2007 and noted pain under the kneecap and the knee felt like it locked up.  The VMO was atrophic and exercises to strengthen it were reviewed.  In February 2008 the CI continued to have knee pain and was placed on limited duty (LIMDU).  A right knee X-ray series on 1 February 2008 showed no significant degenerative change, but there was likely a congenital small protuberance on the undersurface inferiorly in the patella.  On 19 February 2008 the right knee showed a full ROM with pain on flexion and without instability or evidence of a meniscal tear.  In March 2008 the chronic right knee pain persisted, but the examiner indicated the primary problem was more from muscle tightness, which required work on stretching and conditioning.  In April 2008, no significant improvement was noted from physical therapy over the prior 2 months nor was there any improvement by June 2008 when separation was recommended.  

The first LIMDU (limited duty) was issued on 1 February 2008 for Grade 2-3 chondromalacia patella (cartilage degeneration of the knee cap) with a history of 2 years of recurrent right anterior knee pain.  The CI was limited to no deployment, no field duty, no PFT (physical fitness training), no marching, and no group PT (physical training).  The second LIMDU was dated 2 July 2008 for the patellofemoral syndrome  with limitations of no forced runs or humps, no heavy lifting, pushing, or pulling, and exercise at his own pace and tolerance.

The MEB narrative summary (NARSUM) dated 16 July 2008 noted the CI had constant pain in the front of the right knee and beneath the knee cap since boot camp in April 2006, which worsened since returning from deployment in October 2007.  The pain ranged from 6-7/10 (10 being the worst pain).  Examination revealed tight hips and hamstrings.  The right knee showed no effusion or deformities.  There was normal patellar alignment and tracking, normal patellar mobility, and no patellar crepitus.  There was tenderness at the inferior pole and medial and lateral borders of the patella and there was no joint line tenderness.  The ROM was full from 0-150 degrees with pain on full flexion.  There was no laxity or evidence of a meniscal tear.  Strength and sensation were normal as were the CI’s gait and stance.  In spite of rest and physical therapy there was no improvement of the pain that limited his job performance and running, but work on hip and hamstring flexibility and quad conditioning for ongoing management was still needed.  
 
At the MEB examination dated 8 August 2008, the CI reported knee problems with swelling on the DD Form 2807-1.  The MEB physical examiner did not note any physical finding related to the right knee, but included PFPS (patellofemoral pain syndrome) in the summary of defects and diagnoses.  The non-medical assessment dated 20 August 2008 indicated the CI had been on limited duty since 2 February 2008 and was awaiting PEB findings for right knee problems. The CI was working out of his specialty because of the medical condition and was away from command duties for 16 hours per week.  Because of his condition, he could not perform duties in his MOS, and also could not maintain individual training standards of a basic Marine.

At the VA Compensation and Pension (C&P) examination dated 10 September 2008, performed a month before separation, the CI reported weakness, stiffness, swelling with redness along with giving way, lack of endurance, locking, fatigability, and bruising.  He noted the pain was constant and travelled up and down to the hip and ankle.  It was described as aching, sticking, squeezing, and sharp and had a severity of 6-7/10.  It was elicited by physical activity and relieved by rest, but he was able to function with or without medication.  Examination revealed a normal gait.  The right knee was tender on palpation with crepitus and a positive compression test.  The ROM was 134 degrees with pain.  There was no additional limitation of motion although pain had the major functional impact, but there was also fatigue, weakness, and lack of endurance, and no incoordination.  Additionally, there was no instability or evidence of a meniscal tear.

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5099-5003 (degenerative arthritis) for chronic right anterior knee pain.  The VA assigned a 10% rating using code 5260-5024 (Leg, limitation of flexion-Tenosynovitis) for right knee patellofemoral syndrome.  The Board sought a route for a higher rating, but in the absence of ankylosis, recurrent subluxation or lateral instability, a meniscal dislocation or removal, impairment of the tibia and fibula, genu recurvatum or any additional decrease in the ROM, the Board was unable to find any route to a higher rating.  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 chronic right anterior knee pain condition.

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 chronic right anterior knee pain 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.  

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 20140218, 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 4 Jan 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 USN
- XXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXX former USMC  
- XXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USMC 
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXX former USN