RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00546
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20080229

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Rifleman, medically separated for “chronic right anterior knee pain” with a disability rating of 10%.

CI CONTENTION:  “Review 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 upon a 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 - 20071204	VARD - 20080401	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic R Anterior Knee Pain	5099-5003	10%	S/P ACL Reconstruction, R Knee	5260	0%	20080110	
Status Post R Knee ACL Reconstruction 	Cat II					
Alcohol Dependence	Cat IV	Alcohol Dependence 	9399-9326	Willful Misconduct	20080110	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Right Anterior Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his right knee playing soccer in November 2005.  An MRI showed a sprained medial collateral ligament (MCL) and torn anterior cruciate ligament (ACL).  He initially declined surgery and opted for rehabilitation in physical therapy (PT).  This proved to be inadequate and he then underwent right knee surgery in June 2006 to repair a torn anterior cruciate ligament.  Following surgery, the CI had further rehabilitation in PT, but was no able to return to unrestricted duty.  The MEB forwarded “pain in joint involving lower leg” for PEB adjudication.  At the MEB NARSUM examination (dictated by one of the treating orthopedic surgeons) on 1 November 2007, 4 months prior to separation, the CI reported anterior right knee pain with activity, but denied any right knee instability or shifting.  The MEB physical examination noted full range of motion (ROM), but the examiner did not provide the actual ROM measurements.  Prior clinical entries documented full flexion at 140 degrees and full extension at 0 degrees.  Ligamentous instability tests were mostly negative however they did show slightly increased anterior laxity (1 mm compared to the left side), but with a good endpoint and pivot shift was mildly positive.  The CI exhibited discomfort with deep knee bends and patellar grind testing, but his gait was normal.  Signs of meniscal irritation were absent.  A patellar (kneecap) grind test (compression) was positive.  During the MEB examination dated 27 November 2007, 3 months prior to separation, the physical examination showed a normal lower extremity evaluation.  There was no appreciable knee instability discerned with ligament instability testing.  At the 10 January 2008 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported complaints of right knee “weakness, giving way, lack of endurance, and locking.”  Pain was elicited with physical activity.  The physical examination showed limitation of flexion to 120 degrees (140 degrees is normal) and 0 degrees of extension (0 degrees is normal).  ROM was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination.  Examination tests for ligamentous instability were negative.  Painful motion was not documented.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated the right knee condition 0%, coded 5260 (limitation of flexion), citing leg flexion limited to 60 degrees or more and noted a stable knee with pain free motion.  The Board considered the findings.  Multiple ratings for the knee are permissible in the presence of instability and other compensable findings.  In this case, the knee was noted to have laxity of the ACL, but a firm endpoint, at the NARSUM examination which was conducted by an orthopedic surgeon.  The Board noted that this was a consistent finding by more than one orthopedic surgeon.  This supports a 10% rating for slight impairment under the code 5257 (knee, other impairment).  The ROM was noted to be full on most examinations and pain free.  The C&P recorded that flexion was limited to 120 degrees, but this is an outlier.  Regardless, the limitation in flexion was not compensable under the code 5260.  Motion was pain free on the C&P examination.  It was present with deep knee bends on the NARSUM.  X-rays had shown post-operative changes.  A rating of 10% under the code 5003 is also supported.  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 right knee instability, coded 5257 and also a rating for 10% for painful motion with an abnormal X-ray coded 5003.  
 
Contended PEB Condition:  Alcohol Dependence.  This is a condition that does not constitute a physical disability.  The Board also noted that the CI was maintaining sobriety at his last encounter with family practice for this condition, dated 26 March 2007, 11 months prior to separation.  No further clinical entries were in evidence.  In addition, this was not submitted by the MEB as failing retention standards.  The Board therefore has no reasonable basis for recommending this condition as additionally unfitting for a separate rating.  

BOARD FINDINGS:  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10% coded 5257 and 10% coded 5003, IAW VASRD §4.71a.  In the matter of the contended alcohol dependence, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Knee Instability	5257	10%	
Chronic Right Knee Pain s/p ACL Repair	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, 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 03 Nov 16 ICO XXXXXXXXXXXXXXXXXX    
	(c) PDBR ltr dtd 21 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 24 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 21 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 03 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 03 Nov 16 ICO XXXXXXXXXXXXXXXXXX

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

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

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

     b. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

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

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

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

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

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

     i. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

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

     k. XXXXXXXXXXXXXXXXXX, 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.