RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02976
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20081129

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Motor Transport Operator, medically separated for “left anterior cruciate ligament deficient knee, surgically treated,” with a disability rating of 10%.

CI CONTENTION:  The CI contends his left knee continues to affect his daily activities and that his injury is more severe than the rating he received.  His complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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 PEB - 20080903	VARD - 20081231	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left ACL Deficient Knee	5299-5003	10%	Left Knee Condition	5260-5024	10%	20080307	
			Scars, Left Knee	7804	20%	20080307	
Lateral Meniscus Tear	Category II	Related VA entries per above	
Quadriceps Atrophy	Category II		
Chondromalacia of Patella	Category II		
Medial Meniscus Tear	Category II		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Knee Condition.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this CI had left knee surgery in April 2006 for anterior cruciate ligament (ACL) reconstruction, medial meniscus repair, and lateral meniscus debridement (removal of a torn piece of meniscus).  After surgery, he continued to have left knee pain.  In February 2007, arthroscopic surgery was performed on the left knee, and a revision repair was performed.  In January 2008, another left knee arthroscopy was done. In spite of all treatment efforts, the CI continued to have problems with his left knee, and an MEB was initiated.  The MEB forwarded the chronic left knee condition to the PEB for adjudication.  

On 7 March 2008, 8 months before separation, the CI had a VA Compensation and Pension (C&P) examination.  He reported left knee pain and tenderness, more on the medial side, with persistent crepitation.  Pain intensity was 5/10.  His left knee felt unstable when descending stairs.  He noted his left knee had given way about once per month, but he had not fallen down.  His left knee swelled after exercise.  On physical examination (PE), there was slight edema (swelling) about the left knee. The CI reported mild tenderness to palpation (TTP) over the medial and lateral joint lines, and over the patellar tendon.  No knee deformity, increased heat or redness were noted.  Tests for ligamentous laxity or joint instability were negative.  Crepitations were palpable.  Range of motion (ROM) testing revealed flexion to 106 degrees (normal 140) and extension to 0 degrees.  Repetitive testing showed no additional loss of joint function due to pain, fatigue, weakness, lack of endurance or incoordination.  

At the May 2008 MEB narrative summary (NARSUM) examination, 6 months before separation, the CI reported persistent pain on the medial and lateral sides of his left knee, along with a sensation of instability.  He could not run more than 3/4 mile, walk more than 2 miles, climb stairs more than 1½ flights, jump, kneel, or squat without experiencing left knee pain.  On physical examination, he walked with a slow but normal gait.  Knee ROM was 115 degrees bilaterally.  There was a slight difference in quadriceps circumference.  The left quadriceps was 1.5 centimeter less than the right.  Tests for ligamentous laxity or joint instability were negative.  Surgical scars were well healed with no warmth, redness or discharge.  Patellofemoral crepitus was noted during ROM testing.  There was marked joint line TTP both medially and laterally.  

The Board directed attention to its rating recommendation based on the evidence.  The PEB used code 5299-5003 (analogous to degenerative arthritis), and assigned a disability rating of 10%, citing good ligamentous stability despite subjective complaints of instability.  The VA chose code 5260-5024 (limitation of knee flexion, with tenosynovitis), and also assigned a 10% rating, citing painful or limited motion of a major joint. The Board noted that the May 2008 MEB examination was more proximate to separation than the C&P examination.  At the May 2008 MEB examination, there was insufficient ROM limitation to support a 10% rating under VASRD codes 5260 and 5261.  However, the Board found sufficient evidence of pain with use of the knee.  IAW VASRD §4.10 (Functional impairment), §4.40 (Functional loss), and §4.59 (Painful motion), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to pain.  There was no path to a higher rating for the left knee, since there was insufficient evidence of recurrent subluxation, lateral instability, or other seriously disabling joint abnormality which would justify a higher rating.  The 5259 code (Cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the unfitting left knee condition.  

The Board noted the four other conditions (noted in chart above) determined to be Category II by the PEB (conditions that contribute the primary unfitting condition but are not separately ratable) were intertwined diagnoses and the overall knee impairment from all listed diagnoses were subsumed under the PEB’s coding and rating of the left knee.  More than one rating based on the same impairment is prohibited IAW §4.14 (avoidance of pyramiding).  After due deliberation, considering the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the other four knee conditions (Category II).  
BOARD FINDINGS:  In the matter of the left ACL deficient knee, and IAW VASRD §4.10, §4.40, and §4.59, the Board unanimously recommends no change in the PEB adjudication. In the matter of the other four knee conditions, the Board unanimously recommends no change in the PEB determination as Category II.  There were no other conditions within the Board’s scope of review for consideration.  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 20140621, 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 31 May 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:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC

						  	XXXXXXXXXXXXXXXXXXXX
	     				  		Assistant General Counsel
						  	(Manpower & Reserve Affairs)