RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02512
BRANCH OF SERVICE:  MARINE CORPS	SEPARATION DATE:  20031130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Basic Marine) medically separated for right knee medial meniscus tear.  The right knee could not be adequately rehabilitated to meet physical requirements.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  Medial meniscus tear right knee and patellofemoral pain syndrome were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB (IPEB) adjudicated medial meniscus tear right knee condition as unfitting rated 10%, with cited application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The applicant makes no specific contention in his application other than referring to a right knee injury.  The applicant’s complete submission, with attachments, 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 condition 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 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 20031021	VA* - (~4 Mos. Post -Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Medial Meniscus Tear Right Knee	5299-5003	10%	Right Knee Meniscus Tear with Patellofemoral Pain Syndrome	5260	20%	20030718	
Patellofemoral Pain Syndrome Right Knee	Cat II					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20040319 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Right Knee Condition.  The service treatment record (STR) documents that the CI sustained a right knee twisting injury during a 5 kilometer hump.  At a sports medicine encounter, the CI reported a right knee twisting injury where he felt a “pop.”  He complained of immediate pain and he awoke with a swollen knee.  The right knee exam revealed a mild effusion (fluid collection) with anterior, medial, and lateral tenderness.  The range-of-motion (ROM) was full.  The medial collateral ligament (MCL) and lateral collateral ligament (LCL) were stable.  The McMurray (assesses menisci) test was positive suggesting a medial and lateral meniscal tear.  The Lachman (assesses anterior cruciate ligament [ACL]) test was negative.  Strength, sensation, and flexibility were normal.  Right knee X-rays showed no fracture.  The diagnosis listed medial and lateral meniscal tear.  At a sports medicine follow-up, the right knee exam revealed anterior and medial tenderness with no effusion, edema (swelling from excess tissue fluid), erythema (redness) or ecchymosis (bruising).  The active ROM was full.  The McMurray, Apley (assesses menisci), and valgus/varus stress (assesses MCL/LCL) tests were positive.  The Lachman, anterior drawer (assesses ACL), and posterior drawer (assesses posterior cruciate ligament [PCL]) tests were negative.  Strength and sensation were normal.  The diagnosis listed medial and lateral meniscal tear.  At an orthopedic surgery evaluation, the CI complained of intermittent medial and superior right knee pain.  Pain was increased with prolonged flexion.  Knee symptoms were associated with locking and occasional swelling, but were not activity related.  The right knee exam revealed medial joint line tenderness with no effusion.  The active ROM was full.  The patellar compression (pain with patellar compression and quadriceps contraction) test was positive.  The assessment listed suspected medial meniscus tear and patellofemoral pain syndrome ([PFPS] symptom complex of anterior knee pain involving the patella).  The surgeon documented a thorough discussion of treatment options and that the CI deferred surgery.  The MEB narrative summary (NARSUM) by orthopedic surgery, 7 months before separation, recounted the history and interventions.  The CI complained of increasing frequency of medial, intra-lateral, and superior right knee pain.  Pain was intermittent and associated with occasional locking and swelling.  Pain was exacerbated by prolonged knee flexion, stair climbing, marching, and running.  The CI failed conservative management which included anti-inflammatory medications, activity modification, and 2 months of rehabilitation at sports medicine.  The right knee exam revealed medial joint line tenderness.  There was normal patellar tilt and tracking and no effusion or ligamentous laxity.  The ROM was full.  The patellar compression test was positive.  The McMurray test caused pain, and an equivocal click, suggestive of a meniscal tear.  A right knee MRI revealed a small joint effusion, a small cyst posterior to the medial femoral condyle, and a probable tear of the posterior horn of the medial meniscus.  The diagnoses listed right knee medial meniscus tear and PFPS.  The surgeon opined that it was unlikely that symptoms would improve, to allow a return to physical training, without surgical intervention.  She stated “Although surgical intervention would be the standard of care in this situation, it is reasonable for the patient to decline surgery at this time, due to the potential complications and potential lack of complete resolution of symptoms with surgical intervention.”

The VA compensation and pension (C&P) exam recounted the history and interventions.  The CI complained of constant right knee pain with associated stiffness and decreased flexibility.  Symptoms were exacerbated by prolonged walking, running, jumping, and climbing stairs, but did not cause incapacitation.  Active treatment was physical therapy (PT) and anti-inflammatory medications.  The physical exam documented a normal posture and gait without assistive device for ambulation.  The right lower extremity revealed no edema, ulceration, dermatitis, clubbing (pathological bulbous enlargement of finger/toe ends), or cyanosis (bluish discoloration due to insufficient oxygen).  The right knee had a normal appearance, medial and proximal patella tenderness, and “locking” pain.  The right knee active ROM was flexion of 95 (140 normal) and extension of 0 (0 normal) degrees.  The ROM was additionally limited by pain, fatigue, and lack of endurance, but not weakness or incoordination.  Pain had the major functional impact.  The drawer (assesses ACL and PCL) and McMurray tests were negative.  Strength and sensation were normal.  A right knee X-ray was normal.  The examiner restated the right knee MRI findings and noted that the CI had declined surgery and opted for conservative therapy.  The diagnosis listed right medial meniscus tear.  The examiner did not list the diagnosis of right PFPS as the CI did not claim this condition.  At a sports medicine follow-up, the right knee exam revealed medial patella and joint space tenderness.  There was no effusion, ecchymosis, or edema.  The active ROM was full with poor flexibility.  Strength and deep tendon reflexes (DTRs) were normal.  The diagnosis listed right meniscal tear.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5299-5003 (Analogous for degenerative arthritis).  The listed Category II condition (PFPS) was considered to contribute to the unfitting knee condition.  The VA, citing the C&P exam four months before separation, rated the right knee condition 20%, coded 5260 (Leg, limitation of flexion).  The VA cited a right knee twisting injury, meniscus tear by MRI, PFPS, tenderness, locking pain, limited ROM, painful motion, fatigue, and lack of endurance.  The proximate exams (sports medicine, orthopedic, NARSUM, C&P) did not demonstrate a limitation of motion to support a minimum rating under the code 5260 or 5261 (Leg, limitation of extension).  While there was a torn medial meniscus, there was no dislocated meniscus (5258), or symptomatic removed meniscus (5259), for consideration under the respective codes.  There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  Board members agreed that there was sufficient evidence of pain with use, as well objective exam and imaging findings, to support a 10% rating considering VASRD §4.40 (Functional loss) and §4.59 (Painful motion).  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 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 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 20140531, 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 8 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 USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN   
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN  
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 

				XXXXXXXXXXXXXXX
	     			Assistant General Counsel
				(Manpower & Reserve Affairs)