RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01135
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050501

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Seaman Recruit, medically separated for “right knee pain,” with a disability rating of 10%.  The conditions “major depressive disorder [MDD], recurrent, mild,” “social phobia, moderate” and “specific phobias, claustrophobia, acrophobia,” were determined to have existed prior to service (EPTS) and were not rated. 

CI CONTENTION:  The CI’s conditions continue to worsen and impact daily living.  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20050321	VARD - 20070402	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5299-5003	10%	No VA Placement	
Right Femoral Head Stress Fracture	Cat III	Stress Fractures Both Legs	5099-5014	NSC	20050707	
Left Ankle Joint Stress Fracture						
Left Medial Tibial Plateau Stress Fracture						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  --%	

ANALYSIS SUMMARY: 

Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in November 2004 after feeling a pop in the knee during a training exercise.  Review of the STR found a normal X-ray of the right knee (5 November 2004), a negative bone scan of the right knee (12 November 2004) and a magnetic resonance image (MRI) (17 November 2004) with a possible medial plateau bone contusion that did not correlate with the complaint of lateral knee pain.

A physical examination on 8 December 2004 (5 months prior to separation) observed a normal gait.  The right knee range of motion (ROM) was full and there was no knee tenderness.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 15 December 2004, 5 months prior to separation, the CI reported “knee trouble” but did not specify which knee was bothersome.  Physical examination was silent regarding the right knee.  The 15 December 2004 MEB NARSUM examination noted complaints of persistent right knee pain which prevented running more than a quarter of a mile or standing or walking for a prolonged period of time.  The level of pain at the time of the evaluation was 0/10.  Physical examination showed an intact heel, toe and tandem gait.  Right knee extension was 0 degrees (normal 0 degrees) and flexion was 135 degrees (normal 140 degrees).  A test of painful kneecap motion was negative.  Tenderness of the lateral tibial plateau region of the knee was present.  Despite a musculoskeletal history of present illness that focused exclusively on the right knee, the examiner did not render a diagnosis related to the right knee.

At the 6 June 2005 VA Compensation and Pension (C&P) evaluation, performed a month after separation, the CI reported right lateral knee pain that prevented him from walking a mile.  He could stand for 15-30 minutes and intermittently used a cane.  Physical examination showed an antalgic gait.  Right knee extension was 0 degrees, flexion was 140 degrees, and there was no change after repetitive motion.  There was no painful motion, but a “click” was noted laterally at terminal flexion.  There was no crepitation or evidence of patellar or meniscal abnormality.  X-rays were normal and an MRI reportedly showed medial compartment osteoarthritis.    

A second C&P examination on 20 June 2005 observed a limp favoring the right leg.  There was slight crepitus of the right knee during flexion and extension. The examiner rendered a diagnosis of right knee arthralgia.  An additional C&P examination on 7 July 2005 observed a normal gait.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded analogously to 5003 (degenerative arthritis).  The VA did not service-connect the right knee condition.  The panel deliberated if there was a route to a higher rating than the PEB’s 10%.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or a history of surgery to remove a meniscus (5259) to support a rating under these 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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee pain condition.  

Contended PEB Conditions:  Right Femoral Head Stress Fracture, Left Ankle Joint Stress Fracture and Left Medial Tibial Plateau Stress Fracture.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The non-medical assessment (NMA) indicated that multiple stress fractures in both legs were responsible for the CI’s inability to complete training.  At a clinic visit on 8 December 2004 the CI reported that he had no pain.  Examination showed no evidence of pain or tenderness of the left ankle, left knee or right hip.  The profiling section of the DD Form 2808 listed stress fractures of the left tibial plateau, left ankle and right femoral head.  The CI marked “No” for “Impaired use of…legs” and “Swollen or painful joints.”  The examiner reported pain in the right hip and left knee with prolonged weight bearing.  The NARSUM examiner on 15 December 2004 noted that multiple lower extremity stress fractures were present and interfered with completion of Boot Camp, but specified that the right knee pain condition (which was not associated with a stress fracture) was responsible for the inability to run more than a quarter of a mile, or walk or stand for prolonged periods.  Physical examination showed a normal gait and no evidence of left ankle, left knee or right hip pain or tenderness.  The NARSUM’s final diagnoses included stress fractures of the left medial tibial plateau, left ankle and right femoral head.  The examiner stated, “It will likely take six months to one year for the patient’s injuries to heal and restore his physical condition enough to continue military service.”  An examination on 28 March 2005 noted left ankle tenderness.  A C&P examiner a month after separation concluded that bilateral lower extremity stress fractures were healed.

Although stress fractures were implicated in the NARSUM and NMA, there is no evidence from the record that stress fractures interfered with duty performance at separation.  The only specific functional limitations were described by the NARSUM examiner, but those referred to the right knee.  Nowhere were there specific functional limitations attributable to stress fractures, nor was there any documentation of physical examination findings (related to stress fractures) consistent with significant disability.  Furthermore, the NARSUM examiner suggested that once stress fractures healed, pursuit of military service was realistic.  In support of that conclusion was the finding of healed stress fractures one month after separation, which resulted in the VA’s appropriate decision to not service-connect them.  Finally, even if the stress fractures were considered to be unfitting, there was no examination evidence to support a rating higher than 0% for any of them.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right knee pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right femoral head stress fracture, left ankle joint stress fracture and left medial tibial plateau stress fracture conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150609, 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

      In accordance with reference (a), I have reviewed the cases listed below and 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
	 	- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC