RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02339
BRANCH OF SERVICE:  MARINE CORPS 	BOARD DATE:  20150629
SEPARATION DATE:  20090930

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

CI CONTENTION:  “Conditions have gotten worse can’t stand, sit, lay, walk for long periods, cannot walk upstairs issues going uphill knee constantly giving out.  Please consider 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 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 20090805	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Chronic Left Knee Pain 	5257	0%	STR	
Other MEB/PEB Condition x 0 (Not in Scope) 	Other x 3	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20100309 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Knee Condition.  At the 7 November 2008 Battalion Aid Station (BAS) encounter for left knee pain, the CI reported knee pain for a year which started in boot camp and reportedly worsened during deployment.  The diagnosis listed patellofemoral pain syndrome (symptom complex of anterior knee pain involving the patella).  The 8 May 2009 orthopedic surgery encounter documented knee pain for several months with gradual onset and no direct trauma, mainly with exertional activities, really noticeable with running and going up hills as well as stairs.  The CI initially treated by his BAS with light duty and anti-inflammatories and was sent to physical therapy (PT).  With all treatments he voiced no relief of pain.  The CI reported grinding with knee motion, denied locking, but voiced the knee “gives out.”  The left knee exam recorded no erythema [redness], effusion [fluid collection], ecchymosis [discoloration from blood extravasation], or deformity.  Tenderness to the patella femoral border as well as along the patella medially was noted with no joint line tenderness.  No laxity was noted on Drawers/Lachmann’s [assess integrity of cruciate ligaments], McMurrays [assesses integrity of menisci] was negative, valgus and varus stressors [assess medial/lateral collateral ligaments] at 0 and 30 degrees revealed no laxity and his patellar grind [assesses abnormal patellar movement and painful crepitation] was positive.  His patellar apprehension [apprehension or pain on quadriceps contraction with patella displaced] was negative, no muscle atrophy was noted and distal N/V [neurovascular systems] was intact.  Range-of-motion (ROM) was noted as 0-135 degrees.  A left knee X-ray revealed no fractures, dislocations, effusion, or evidence of osteochondritis dissecans (fragment of cartilage and bone separating from joint surface).  The diagnosis listed left knee patellofemoral syndrome.  The orthopedic surgeon performed a left knee intraarticular (joint) injection with local anesthetic (lidocaine, marcaine) and corticosteroid (kenalog).  The narrative summary by orthopedic surgery, 3 months prior to separation, recounted the history and interventions to date.  The CI failed several months of conservative management to include activity modification, PT, anti-inflammatory medications, and a joint injection.

The ROM evaluations 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)	PT ~10 Mo. Pre-Sep
	PT ~8 Mo. Pre-Sep
	MEB ~3 Mo. Pre-Sep
	
Flexion (140 Normal)	Full ROM	Full ROM	135	
Extension (0 Normal)	Full ROM	Full ROM	0	
Comment	No pain with Motion	Pain with Motion	TTP noted	
§4.71a Rating	0%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB, 2 months prior to separation, rated the left knee condition 10%, coded 5099-5003 (rated by analogy, degenerative arthritis).  The VA rated the left knee condition 0%, coded 5257 (knee, other impairment of) citing failure to show for the C&P exam.  The proximate PT and MEB exams did not demonstrate limitation of motion to support a minimum rating under VA codes 5260 or 5261 for limitation of flexion or extension.  There was no instability, dislocated meniscus, or removed meniscus to support minimum ratings under the respective codes 5257, 5258, 5259.  Board members agreed that there was sufficient evidence of painful motion (§4.59) prior to separation, as well objective exam findings, to support a 10% rating under 5099-5003.  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 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.

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 20140512, 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 XX Sep 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 USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC