RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02853
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20150723
SEPARATION DATE:  20030731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Infantry) medically separated for a right knee condition.  The 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).  The right knee condition, characterized as “posterior cruciate ligament tear, right knee, non-operative candidate,” “resultant pain and laxity due to condition #1,” and “mild patellofemoral pain syndrome right knee,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “posterior cruciate ligament tear, right knee, non-operative candidate,” as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions “mild patellofemoral pain syndrome right knee,” and “resultant pain and laxity,” were adjudicated as Category II (contributing to unfit condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “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 20030502	VA* - (~1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posterior Cruciate Ligament Tear, Right Knee	5257	20%	Residuals, Right Knee Posterior Cruciate Ligament Tear	5299- 5262	10%	20030613	
Mild Patellofemoral Pain Syndrome Right Knee	Cat II					
Resultant Pain And Laxity	Cat II					
Other Conditions x 0 (Not In Scope)	Other x 6 	
RATING:  20%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20030805 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Posterior Cruciate Ligament Tear, Right Knee.  Treatment records evidence that the CI initially presented with knee pain in March 2002.  He was diagnosed with a posterior cruciate ligament (PCL) rupture and treated conservatively.  At an evaluation dated 23 April 2002 that examiner suspected patellofemoral syndrome as the cause of the CI’s right knee pain.  The CI was referred to physical therapy.  A magnetic resonance imaging study performed on 24 June 2002 did not visualize the PCL and the radiologist opined that this represented a rupture.  There was no evidence of meniscal or anterior cruciate pathology.  An orthopedic note dated 24 March 2003 documented that reports of improved, but continued right knee pain.  The examiner noted that the CI completed physical therapy, continued PT exercise on his own, and was “not interested” in a “PCL reconstruction.”  Radiographic evaluation performed on 23 June 2003 demonstrated changes consistent with erosive or degenerative arthritis.

The narrative summary (NARSUM) referenced a prior medical Board in July 2002 which recommended 6 months of limited duty.  At the NARSUM examination that CI reported daily right knee pain that was worse in the morning, with prolonged sitting or standing, and with jogging or running type activities.  He also reported right knee laxity two to three times per week with prolonged standing and heavy lifting.  The right knee examination demonstrated mild tenderness to palpation, a positive patellar grind, a positive testing for PCL laxity (posterior and a positive posterior draw).  Diagnoses of PCL tear with resultant pain and laxity and mild patellofemoral pain syndrome of the right knee were rendered.  At the VA Compensation and Pension exam performed a month prior to separation, the CI reported that he was not able to sit for prolonged periods of time, carry heavy objects, or perform physical training due to right knee pain, laxity, and weakness.  He did not take any medications for pain.  The right knee examination demonstrated normal flexion and extension with pain at the end of flexion.  There was “significant” crepitus and a positive drawer sign.  The examiner rendered diagnoses of right PCL tear with resultant pain and laxity and patellofemoral pain syndrome.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee PCL condition at 20% for moderate instability; coded 5257 (knee impairment other). The VA rated the condition at 10% for slight knee disability; coded 5299-5262 (analogous to tibia and fibula, impairment of).  The Board considered whether the evidence supported a higher than 20% rating.  There was no evidence of leg limitation or flexion to 10 degrees, extension limited to 20 degrees, marked knee disability, or severe instability for a higher rating.  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 PCL condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right knee mild patellofemoral pain syndrome and the pain and laxity associated with the PCL condition were Category II conditions (contribute to the unfitting condition).  The Board’s threshold for countering Category II determinations requires that the condition could be reasonably justified as separately unfitting, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board noted that pain and laxity were symptoms of the PCL tear which resulted in the 20% rating for the unfitting right knee and therefore, it is not a separately unfitting condition. The Board then considered the mild patellofemoral pain syndrome. Pain in the knee is the primary clinical presentation of patellofemoral pain syndrome.  The Board determined that it would be speculative to differentiate the pain associated with the PCL tear from that of the patellofemoral pain.  The Board also noted that IAW VASRD 4.14 (avoidance of pyramiding) the pain in the right knee could not be used for multiple ratings.  After due deliberation in consideration of the all the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB Category II determinations for the right knee mild patellofemoral pain syndrome and the pain and laxity associated with the PCL condition; therefore, no additional disability ratings are recommended.

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 PCL condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee mild patellofemoral pain syndrome and the pain and laxity associated with the PCL tear conditions, the Board unanimously recommends no change from the PEB determinations as Category II.  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 20140609, 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 1 Dec 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:

- XXXXXXXXXXXXXXXXXXX, former USMC  
- XXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)