RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00879
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20141126
SEPARATION DATE:  20041115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty LCPL/E-3 (9971/Basic Marine) medically separated for chronic right knee pain.  The knee condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was placed on limited duty and eventually referred for a Medical Evaluation Board (MEB).  The knee conditions, characterized as “pain in joint, lower leg” and “chondromalacia patella” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chronic right knee pain,” as unfitting, rated at 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The IPEB also adjudicated the “history of recurrent patella dislocations,” as a related Category II condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “1  9 in scar on R knee has been painful (opening up, oozing puss, scabbing over) since my reconstructive surgery Oct 02’.  2  Records indicate a diagnosis of chronic synovitis in at least 03’.  3  Painful screw in right tibial area was recognized and removal recommended.  4  My records indicate a diagnosis of chronic/severe chondromalacia patella R knee (aka patellafemoral [sic] syndrome in 2002.” 

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 those conditions identified, but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting chronic right knee pain condition is addressed below (includes the Category II condition).  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records. 

The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected conditions continue to burden her.  The Board also acknowledges the CI’s contention that suggests a higher rating should have been granted on the unfitting medical condition documented at the time of separation.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

RATING COMPARISON:

Service IPEB – Dated 20040928	VA - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5299-5257	10%	Right Knee Chondromalacia Patella Status Post Recurrent Patellar…	5299-5257	10%	STR	
			Scar, Status Post Right Knee Surgery	7804	10%	STR	
History of Recurrent Patella Dislocations	Category II					
Other x 0 (Not In Scope)	Other x 0	
Rating:  10%	Combined:  20%	

ANALYSIS SUMMARY:  The Board unanimously agreed the Category II condition was part and parcel of the chronic right knee pain condition and will discuss them as one.

Right Knee Condition.  The narrative summary (NARSUM) notes the CI to develop recurrent episodes of dislocation of her right patella (knee-cap) during training.  A magnetic resonance imaging (MRI) of the knee performed on 31 July 2002, revealed “tilting” of the patella and no evidence of ligament or meniscus (cartilage) injury.  A surgical procedure was undertaken on 11 October 2002 to stabilize the patella and prevent further dislocation.  The procedure was successful in preventing recurrent dislocations, but a painful knee condition developed.  On a 21 July 2003 orthopedic evaluation, the examiner reported that the CI had increasing painful motion of the knee with crepitus (grinding) and “popping” was reported.  Range-of-motion (ROM) of the right knee was flexion 130 degrees (normal 140 degrees) with pain and extension was normal.  The knee was stable with no evidence of dislocation or instability of the patella (subluxation or apprehension).  Routine X-ray images revealed the “patella to be in good position.”  A second operative procedure (arthroscopic) was performed on 12 August 2003 for increasing knee pain.  Findings at this surgery were normal ligaments and tendons, but severe irritation of the lining of the knee and irregularity of the patella (synovitis and chondromalacia).  Removal of part of this irritated lining was undertaken (synovectomy).  Following this surgery the CI had continued knee pain but no episodes of patellar dislocation.  

At the 12 February 2004 MEB NARSUM exam (approximately 9 months prior to separation), the CI reported continued pain, stiffness, crepitus and “grinding” in her right knee with activity.  The MEB physical exam noted the CI to be in no distress.  Flexion of the knee was 135 degrees with pain; extension was normal.  There was no instability of the knee or patella.  At an orthopedic evaluation on 22 April 2004, the CI reported no patellar dislocations since August 2003 and being able to ride a bicycle.  On exam, the CI gait was normal; no swelling or knee/patellar instability was present and flexion was 140 degrees with pain.  On an orthopedic exam on 15 July 2004, the CI reported her patella tends to slip slightly in flexion and then jumps back.  She also complained of pain at a surgical “screw site” in her right upper lower leg (tibial plateau) which she wanted removed.  ROM of the knee was ‘full’ with pain.  Stress X-rays of the knee revealed no evidence of patellar instability or subluxation.  The screw was removed surgically in mid July 2004.  Post-operatively a small wound infection (stitch abscess) occurred which was treated with wound care.  On a 23 August 2004 emergency department visit for wound care, the CI was noted to ambulate without difficulty.  

The VA Compensation and Pension scheduled for 15 October 2004 (a month prior to separation), was not in evident due to non-attendance.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and VA, using service treatment records, both rated the knee condition 10% using code 5257 (recurrent instability, subluxation/slight).  The next higher rating under this code, 20%, requires the condition to be “moderate.”  The highest rating, 30 % requires the condition to be “severe.”

The Board unanimously agreed the knee condition rose to the level of 10%, for painful motion IAW §4.59.  The Board agreed the record in evidence did not support a rating, under ROM codes.  The Board considered a rating under code 5257, (knee/patella instability).  The Board noted the reports by the CI of the knee “giving way” and “popping” in the treatment records.  The Board agreed that the CI had a condition of patellar instability, but this condition was successfully corrected by surgery.  The Board agreed the preponderance of evidence in record after the surgical procedure of October 2002 (2 years prior to separation), supported neither knee nor patellar instability.  The Board unanimously agreed this condition was not present/not unfitting and, thus, could not recommend a rating.  The Board agreed that no rating could be recommended under code 5258 (cartilage dislocated) as the record recorded no “frequent episodes, of locking or effusion of the knee,” imaging confirmed no loose cartilage and clinical examination confirmed no mechanical locking or signs of cartilage impingement.  The Board considered a rating under code 5262, (knee impairment) but unanimously agreed the knee condition did not rise to the level of “moderate severity” required for a 20% rating.  The Board considered a rating under code 7804 (scars) but was unable to do so as scars were described as well healed and stable, only moderately tender and having no impact on joint function.  The Board found no other appropriate codes for rating consideration or pathway to a rating higher than 10% for the knee condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the right knee 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 right 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.

RECOMMENDATION:  The Board, therefore, recommends 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 20140222, 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 29 Apr 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:

- XXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USN