RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	 CASE:  PD-2014-01325	
BRANCH OF SERVICE:  MARINE CORPS 	 BOARD DATE:  20150105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Avionics Technician) medically separated for chronic left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The left knee pain condition, characterized as “pain in joint involving lower leg” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded three other conditions (obesity, tension headache and lumbago) for PEB adjudication.  The informal PEB adjudicated “chronic knee pain” as unfitting, rated 0%.  The remaining conditions were determined to be category III (tension headaches and intermittent uncomplicated functional lower back pain) which are not separately unfitting and do not contribute to the unfitting condition and category IV (obesity), which does not constitute a physical disability.  The CI made no appeals, and was medically separated.

CI CONTENTION:  His left knee continues to affect 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, 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:  
   
Service IPEB – Dated 20091007	VA* - (5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Left Knee Patellofemoral Syndrome	5019	0%	20100415	
Other MEB/PEB Conditions x 3  (Not in Scope)	Other x 9 	20100415	
Combined:  0%	Combined:  10%	
*Derived from VA Rating Decision (VARD) dated 20100706 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY: 

Chronic Left Knee Pain Due To Patellofemoral Pain Syndrome.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s left knee condition began in September 2006 when he injured his knee doing lunges during physical training.  The CI stated that he heard a pop followed by immediate pain.  He subsequently complained of persistent left knee pain with running and going up and down stairs.  X-rays of the left knee were normal, however an MRI revealed chondromalacia patella (softening and fissuring of cartilage surface of the joint) consistent with the clinical diagnosis of patellofemoral pain syndrome (typically manifesting as anterior knee pain worse with squatting, going up and down stairs and running).  There were no tears of the menisci or ligaments on the MRI.  There was also a medial popliteal cyst suggesting meniscal tear, but no meniscus tear was visualized on the MRI and examinations were repeatedly negative for symptoms or signs of meniscus pathology.”  There was no surgical indication.  Despite treatment, including the use of a patellar stabilizing sleeve, 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 a Medical Evaluation Board (MEB).  The range-of-motion (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)	MEB 
~ 7 Mo. Pre-Sep	NARSUM 
~ 5 Mo. Pre-Sep	VA C&P 
~ 5 Mo. Post-Sep	
Flexion (140 Normal)	FROM	120	140	
Extension (0 Normal)	FROM	0	0	
Comment	Full Range of Motion
+/- Patellar grind noted in both knees
No instability
No meniscus signs
Strength normal	+ Patellar Grind
Negative patellar apprehension
No instability
No meniscus signs
Strength normal
Gait normal	+ Crepitus both knees
No painful motion
No instability
Gait Normal
	
§4.71a Rating	0%	0%	0%	
 
At the time of the civilian physical therapy examination, 16 December 2008 (11 months pre-separation), the CI complained of intermittent pain causing difficulty squatting and running.  Left knee range-of-motion was flexion 135 degrees and extension 0 degrees, and was identical to the right knee range-of-motion.  At the MEB examination (recorded on DD Form 2807 and 2808) dated 23 April 2009, the knee exam was normal except for discomfort with patellar compression / grind noted to be present in both knees.  The MEB NARSUM, 10 June 2009 (5 months before separation), noted persistent left knee pain preventing USMC duties.  The CI reported left knee pain with impact exertion as well as low impact activities such as when arising from seated position, with stair climbing and squatting.  The knee pain prevented all activity involving running.  The CI also reported pain with maneuvering on aircraft to perform maintenance duties.  The examiner noted: 

In March 2009, he was enrolled in the VMAT-203 combat lifesaver course. The final test of the course includes hill/terrain running, simulations of movement under fire, and fireman carry of a fellow Marine simulating combat transport of a wounded Marine. LCpl Lucius was observed by the course instructor to complete all events of the course with obvious difficulty.

On examination, the MEB NARSUM examiner noted a normal gait without antalgia, no ligamentous instability, and no meniscus signs.  The patellar grind test was positive for patellofemoral pain but a related test, the patellar apprehension test was negative for patellofemoral pain.  Flexion was slightly reduced as noted in the chart.  At the VA Compensation and Pension (C&P) examination, 23 April 2010, performed 5 months after separation, the CI reported some retropatellar pain and crepitation but stated that he was able to perform his normal job (technician at an ethanol bio-refinery) and normal daily activities.  No flare-ups were noted.  Range-of-motion was normal (see chart) without pain.  There was some crepitation noted in both knees.  There was no instability, and no change with repetition.  The gait was normal. Gait and strength was normal on neurologic examination 4 May 2010.  X-rays of the left knee were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left knee pain condition 0% (coded 5099-5003, analogous to degenerative arthritis).  The Navy PEB listed the left knee patellofemoral pain syndrome condition as a related diagnoses (Category 2) contributing to the disability in this case.  The Board noted that the patellofemoral pain syndrome was the underlying diagnosis causing the chronic left knee pain and was not a separate condition which could be separately rated (§4.14 (avoidance of pyramiding).  The VA rated the left knee condition 0% (coded 5019, bursitis), citing the normal painless range of motion without other functional limitations reported by the CI or noted on examination at the time of the VA C&P examination.  The VA and Service exams all reflect that there was no limitation of motion which attains a minimum rating under the diagnostic codes for limitation of flexion or extension, and neither the Service nor VA evidence indicated the presence of ligamentous instability or laxity, or frequent locking with effusions (or any indication of dislocated meniscus or loose body).  There was no evidence of painful motion with functional loss that would support a 10% rating (based on §4.59, §4.40 and §4.45).  At the time of the MEB NARSUM examination, the CI reported functional impairments due to left knee pain in routine occupational activities and the Board discussed if a 10% rating was supported based on functional loss (§§ 4.40, 4.45, 4.59).  However, the Board noted the CI was able to complete extremely strenuous training (although with pain) before separation and that shortly after separation the CI did not report functional loss in his occupation or routine daily activities despite his knee condition.  Although the CI was not able to perform strenuous military duties, the preponderance of evidence indicated there was not any significant functional impairment in routine occupational duties including in his post-separation civil occupation.   There is therefore no VASRD §4.71a route to a rating higher than the 0% 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 left 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 chronic left 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 recharacterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140310, 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 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:

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

				XXXXXXXXXXXXXXX	     				  		Assistant General Counsel
				(Manpower & Reserve Affairs