RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03843
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20050818

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Support Equipment Mechanic, medically separated for “chronic left knee pain status post anterior cruciate ligament repair and medial /lateral meniscus repairs,” with a disability rating of 10%.  

CI CONTENTION:  The CI asserts his left knee injury and right shoulder injury caused his right knee and left shoulder injuries.  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 - 20050504	VARD - 20060224	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain … ACL and Meniscal Repairs	5099-5003	10%	Degenerative Joint Disease, Left Knee	5010-5257	10%	20060214	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain Status Post Anterior Cruciate Ligament Repair and Medial /Lateral Meniscus Repairs Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left knee surgery in September 2001 for a ruptured anterior cruciate ligament (ACL).  The CI had multiple re-injuries of his left knee and a second surgery was performed in September 2004 for repair of meniscal tears.  Radiographs in March 2005 (MRI) demonstrated evidence of frank ACL insufficiency (only a portion of the graft remaining) with intact menisci.  Despite treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.  

The range of motion (ROM) evaluations in evidence 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)	MEB ~5 Mo. Pre-Sep	VA C&P ~6 Mo. Post-Sep	
Flexion (140 Normal)	“Normal”	130	
Extension (0 Normal)		0	
Comment:  Surgery ~11 Mo. Pre-Sep	Slight laxity
(see text)	Crepitus; slight laxity
(see text)	
§4.71a Rating	10%-20% (PEB 10%)	10%-20% (VA 10%)	

At the MEB NARSUM examination on 25 March 2005, performed 5 months before separation, the CI reported chronic left knee pain since surgery (6 months prior).  The MEB physical examination noted a normal gait and normal deep tendon reflexes with no sensory deficits and normal muscle strength (5/5).  The ROM was noted as normal.  The DD Form 2808, Report of Medical Examination, accomplished that same day indicated left ACL with slight laxity and the examiner indicated “chronic left knee ACL insufficiency.”  

At the VA Compensation and Pension (C&P) examination on 25 February 2006, performed 6 months after separation, the CI reported pain of 2/10 at rest; with increase to 5/10 with activity.  The CI indicated his knee was not bothered by standing or walking but was aggravated by lifting 50 pounds or going up and down stairs.  He also reported that he was unable to run.  Additionally, he reported he took no medication for his knee.  There were no complaints of locking or giving way.  The physical examination showed no tenderness or fluid.  There was slight crepitus with flexion and slight laxity with medial and lateral compression.  The Lachman’s test was slightly positive (for laxity).  The range-of-motion was 0-130 degrees (normal 0-140) without pain on motion.  Radiographs documented degenerative joint changes.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10% analogous to code 5003 (arthritis degenerative).  The VA rated the left knee condition 10% coded 5010-5257 (arthritis due to trauma – with knee impairment:  recurrent subluxation or lateral instability), citing the presence of slight laxity with medial and lateral compression of the knee based on the post-separation C&P examination.  

There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was not clear evidence of painful motion or pain-limited motion and the CI’s disability condition was principally due to meniscal and anterior cruciate injuries and surgical repairs.  The CI had chronic knee pain and had had meniscal surgery so a 10% rating was considered supported under analogous VASRD diagnostic code 5259 (cartilage, semilunar, symptomatic); however this coding would include any arthritis and/or painful motion under the PEB’s analogous 5003 coding which was an acceptable alternative coding.  The evidence did not did demonstrate frequent “locking” and effusions into the joint or any indication of dislocated meniscus or loose body for a higher meniscal rating under code 5258.  

The Board considered if dual rating of the knee was supported with additional rating under code 5257 (for instability).  There were no subjective complaints of instability or giving way of the knee, although objective testing at the MEB and VA examinations both documented the presence of slight ligamentous instability or laxity.  There was no evidence that laxity was greater than slight (10% rating criteria).  The Board deliberated if there were sufficient symptoms and finding for an additional 10% instability rating, in addition to the 10% for analogous rating under 5003 or 5259, with consideration of VASRD §4.14 (avoidance of pyramiding) as well as VASRD §4.3 (reasonable doubt).  The examinations proximate to separation clearly documented slight ligamentous laxity and insufficiency and rating for instability does not include pain or painful motion.  The CI had chronic pain with increase with activities following multiple knee injuries and meniscal surgery.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee pain (with meniscal surgery and traumatic arthritic changes) plus an additional 10% for the left knee slight laxity (ACL insufficiency) condition.  

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends dual rating of the left knee with a disability rating of 10%, coded 5099-5259; and a disability rating of 10%, coded 5299-5257; both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain Status Post Anterior Cruciate Ligament Repair and Medial/Lateral Meniscus Repairs	5099-5259	10%	
	5299-5257	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140629, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 26 Jan 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Jan 16 ICO XXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (XX) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
     e. XXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10%) effect date of discharge.
 
     f. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     h. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.