RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04254
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20070531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aviation Communication Systems Technician, medically separated for “chronic right knee pain,” rated 10%.

CI CONTENTION:  “Please consider all conditions.”  The CI’s 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 based on 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 - 20070316	VARD - 20071103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5299-5003	10%	Right Knee S/P ACL Reconstruction	5257	20%	20070714	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right knee surgery in August 2005 for reconstruction of the anterior cruciate ligament (ACL).  The CI had a history of two prior surgeries on the right knee, including a previous ACL reconstruction in 1996.  At post-operative visits the knee was stable on examination but anterior knee pain continued.  No further surgery was recommended and further treatment did not result in improvement sufficient to allow unrestricted duty.  The CI was referred for a MEB which forwarded “chronic knee pain” for PEB adjudication.

The MEB NARSUM dated 19 October 2006 (7 months prior to separation), noted complaints of continued anterior knee pain causing an inability to kneel or squat.  The CI reported mild swelling but denied instability, and was taking a non-steroidal anti-inflammatory drug (NSAID).  Physical examination noted a normal gait.  The surgical incisions were well-healed and there was no swelling.  There was no objective pain with motion of the knee and the knee cap tracked properly in motion.  Tests for lateral instability, instability of the anterior and posterior collateral ligaments, and meniscal pathology were negative.  Additional testing for ACL injury (Lachman) indicated minimal laxity (1+, or 1-5 mm laxity of the joint) with a firm end point (indicates an intact ACL).  Knee range of motion (ROM) was 130 degrees (normal 140) of flexion and 0 degrees (normal) of extension.  Right knee X-rays indicated a normal knee with expected surgical changes (including retained hardware); no degenerative changes were apparent.

At the time of a sports medicine appointment on 15 November 2006, 15 months after surgery and 7 months prior to separation, the CI reported right knee pain worse in the morning and at the end of the day.  On examination, the knee was tender and had fluid accumulation (effusion) with bruising.  There was tenderness to palpation along the patella and patellar tendon and ROM was reported as “full.”

At the 14 July 2007 Compensation and Pension (C&P) evaluation (2 months after separation), the CI reported constant right knee pain (rated 6/10 in severity) elicited by prolonged standing, walking, stress, and activity.  The pain was relieved by rest and NSAIDs.  The CI reported giving way, fatigability and swelling after exercise, but the condition did not cause any incapacitation.  Physical examination showed a normal gait and no guarding.  There was objective tenderness of the joint, but no swelling, effusion, weakness, or abnormal movement.  Knee ROM was measured from 0-140 degrees initially, but reduced by 10 degrees (due to pain) with repetition.  Tests for ligamentous stability and meniscal integrity were normal and X-rays revealed evidence of the previous ACL repair.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee 10%, coded 5299-5003 (analogous to degenerative arthritis).  The VA rated the right knee 20%, coded 5257 (other knee impairment), citing additional loss of ROM on repetition due to pain, based on the VA C&P examination 2 months after separation.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261); however, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) at the VA C&P examination.  The examinations proximate to separation (after the second ACL repair) did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of residual instability.  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:  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.  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 20141023, 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 10 Jun 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:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC