RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01797
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20140806
Separation Date:  20070615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (7041/Assistant Operations/Ground Training Chief) medically separated for a right knee condition.  The right 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 (LIMDU) three times and was referred for a Medical Evaluation Board (MEB).  The knee condition, characterized by the MEB as “pain in joint involving lower leg” and “non allopathic lesions of lower extremities, not elsewhere classified,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “right knee patellar tracking dysfunction” as unfitting, rated 10%, with chronic right knee pain as a related Category 2 condition, one which contributes to the unfitting condition but is not separately ratable.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Service connected spinal fusion surgery and currently 4 service connected knee surgeries.  My way of life has changed since these surgeries.  Please review all conditions.”

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 knee condition is addressed below.  The contended spine condition was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions 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.

RATING COMPARISON:

Service IPEB – Dated 20070328	VA - (3 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Patellar Tracking Dysfunction	5299-5003	10%	S/P Arthroscopic Surgery, Right Knee Strain with Residual Scar	5299-5258	20%	20070919	
Chronic Right Knee Pain	CAT 2					
Other x0 (Not in Scope)	Other x8	20070919	
Rating:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20080131 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The Board acknowledges the impairment with which the CI’s service-connected condition continues to burden her but notes the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  Additionally, the Board acknowledges the presence of lumbar strain as a service-connected condition by the DVA, but notes that the scope of its recommendations does not extend to conditions which were not diagnosed or in evidence at the time of medical separation.  This includes conditions which may have had early manifestations during active service, since such sub-clinical conditions cannot be correlated with a fitness determination requisite for a disability rating.

Right Knee Patellar Tracking Dysfunction Condition: The PEB coded the chronic knee pain condition as a Category II condition (“Conditions that contribute to the unfitting condition”).  This Category II condition will be discussed under the unfitting condition.

The CI underwent the following right knee surgeries:
1.	20010322 Right knee arthroscopy with lateral release
2.	20060117 Right knee arthroscopic revision of lateral release and distal realignment
3.	20070109 Right knee arthroscopic synovectomy with hardware removal
There was one goniometric range-of-motion (ROM) evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, as summarized in the chart below.

Right Knee ROM (Degrees)	MEB 3.5 Mos. Pre-Sep	VA C&P 3 Mos. Post-Sep	
Flexion (140 Normal)	Full ROM	70	
Extension (0 Normal)		0	
Comment	Pos tenderness to palpation; No ligamentous laxity; Pos crepitus & patellar apprehension; Normal strength & sensation	Normal gait; Pos painful motion, effusion & tenderness; Pos Deluca criteria; No subluxation; Normal strength & sensation	
§4.71a Rating	10%	10%	

The CI sustained injury to her right knee after a misstep off of a log during physical training (PT) while in Boot Camp in March 2000.  The CI complained of anterior and retro patellar knee pain that worsened with weight-bearing and flexion of the lower leg.  Despite extensive physical therapy, crutches and a knee immobilizer, the pain persisted.  She was seen by Navy Orthopedics in October 2000 for pain localized to the lateral joint line with episodic clicking, popping, locking and a feeling of instability along with continued pain on weight-bearing.  The CI was placed on her first LIMDU in early 2001.  A right knee magnetic resonance imaging (MRI) showed a partial tear to the inner fibers of the lateral collateral ligament.  A second opinion, obtained at a different Navy hospital, opined that the MRI findings were related to an old injury.  Because of ongoing right knee pain, the CI was referred to a civilian medical center and was diagnosed with excess lateral patellar pressure.  On 22 March 2001, the CI underwent a right knee arthroscopy with lateral release.  The CI developed new right knee pain and fell to the ground when her knee gave out after intense training in preparation for Drill Instructor school.  The examiner documented diffuse tenderness to palpation (TTP) at the patella, proximal tibia and distal femur with an inability to flex the knee.  The CI was referred to physical therapy for evaluation and treatment.  She was seen by Orthopedics for lateral right knee swelling and joint stiffness, a clicking sensation and an episode in which the right knee suddenly locked up.  The physical exam findings were mild generalized effusion, and anterolateral, lateral joint line and lateral TTP.  The Orthopedist diagnosed an acute meniscal tear and ordered a repeat MRI.  A right knee MRI showed no definite meniscal tear.  A right knee arthrocentisis to remove the fluid which caused the patellar effusion was performed on 1 August 2005.  The CI was again placed on LIMDU from 13 October 2005 to 13 April 2005 for right patellar subluxation.  On 17 January 2006, the CI underwent a right knee arthroscopic revision of the lateral release and distal realignment because the initial lateral release failed.  The CI underwent a right sciatic nerve block for severe post-operative pain on the same date as the surgery.  A right knee X-ray showed some increase in osseous healing although complete osseous union had not yet occurred.  The CI continued with right knee follow-up by physical therapy and Orthopedics.  The CI was placed on LIMDU a third time from 4 April 2006 to 4 October 2006.  A repeat right knee X-ray showed progressive healing.  The civilian Orthopedist noted that the CI was no longer having subluxation issues; however, she was still having some minor discomfort from some of her retained hardware.  She underwent a right knee arthroscopic synovectomy with hardware removal on 9 January 2007; the operation report documents “No meniscal Pathology.”  The MEB narrative summary (NARSUM) exam approximately 3 months prior to separation documented that right knee arthralgia occurred with weight bearing, ambulation, running, squatting, kneeling, full extension and standing for long periods of time.  She was unable to go to the shooting range due to inability to assume positions that were required to fire her weapon.  The examiner further noted that the CI was advised that she would have chronic knee pain associated with various activities and she would likely require ongoing therapy and medical follow-up.  The MEB NARSUM physical exam findings are summarized in the chart above.  The non-medical assessment documented that the CI had recent surgery and was not likely to be able to complete a physical fitness test; however if she was retained until her expiration of active service, she would still be able to perform her duties and also complete her physical therapy.  The VA Compensation and Pension (C&P) exam approximately 3 months after separation documented right knee weakness, stiffness, swelling, give-way and lack of endurance with constant aching, sharp cramping pain rated at nine.  The pain was elicited by physical activity and relieved by ice and rest.  She was using knee braces, crutches and medications and attending physical therapy.  Her functional impairment was an inability to squat, kneel or run, and difficulty walking up and down stairs.  The VA C&P physical exam findings were summarized in the chart above.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the right knee patellar tracking dysfunction condition as 5299 analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated it 10%.  The VA coded the status post arthroscopic surgery, right knee strain with residual scar condition as 5299 analogous to 5258 cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint” and rated it 20%.  The evidence did not contain any indication that the CI’s semilunar cartilage was dislocated and to the contrary, the operation report five months prior to separation documented “No meniscal pathology.”  There were no provider notes for treatment of any knee dislocation, just the CI’s subjective report of instability and “giving out” which are commonly due to pain.  All ROM testing of the right knee resulted in non-compensable measurements with no exam evidence for knee instability.  The Board considered the coding schema of 5258 versus 5257 knee, other impairment of: recurrent subluxation or lateral instability rated at 20% moderate.  Board members agree that there was no evidence contained in the file to support recommendation of a knee specific VASRD code or that any evidence supported a coding and rating scheme which would result in a rating higher than 10%.  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 patellar tracking dysfunction 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 patellar tracking dysfunction 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 20140421, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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 26 Feb 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:

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

						  XXXXXXXXXXXXXXX
	     				  Assistant General Counsel
		(Manpower & Reserve Affairs)