RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01165
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20090330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Field Radio Operator, medically separated for “left knee quadriceps weakness and functional instability” with a disability rating of 10%.  

CI CONTENTION:  His injuries continue to be a problem today.  His left knee still has pain and he is still suffering from sleep loss and anxiety associated with PTSD from two combat deployments.  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 -  20090114	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Quadriceps Weakness and Functional Instability	5099-5003	10%	No VA examination proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA 	

ANALYSIS SUMMARY:  

Left Knee Quadriceps Weakness and Functional Instability.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent ACL reconstruction surgery on 7 September 2007.  Postoperative X-rays showed a failed femoral fixation which was surgically corrected with success the next day.  The CI received physical therapy (PT) and regained range of motion (ROM) as expected within 3-4 weeks after surgery and was ambulating well with no complaints of instability.  His surgeon then deployed for over 7 months, and the CI reportedly was not provided guidance to progress to the final stages of ACL rehabilitation.  Left knee re-evaluation, upon his surgeon’s return in August 2008, revealed moderate to severe quadriceps weakness.  An earlier 28 June 2008 MRI indicated the ACL graft appeared intact with no evidence of meniscal injury.  At the 7 August 2008 PT visit, 7 months before separation, the CI reported feeling increased left knee pain and swelling after running.  Physical examination showed full ROM with mild discomfort at end-range flexion bilaterally, and positive McMurray’s testing (for meniscus damage) bilaterally, left greater than right.  

At the 2 September 2008 sports medicine clinic appointment, 6 months prior to separation, the CI complained of continued feelings of left knee instability as well as mostly medial-sided pain with exertion and attempted rehabilitation.  ROM was flexion to 135 degrees (normal 140) and extension to 5 degrees (normal 0) with no mention of painful motion.  The CI did have mild medial joint line tenderness and some midline tenderness about the patellar tendon.  He also had moderate to severe vastus medialis and moderated generalized quadricep atrophy in his left leg.  The examiner assessed that the CI had left knee residual weakness and prescribed an unrestricted aggressive strengthening program for the left quadricep muscles.  At a follow-up appointment with the same provider on 21 October 2008, the CI could not to squat any significant amount of weight without both thighs giving out.  The examiner recorded full left knee ROM with a stable anterior drawer and only slight laxity compared to the right knee.  There was also visible left thigh quadriceps atrophy compared to the right.  The examiner noted the CI was approaching the end of his second limited duty period and would not be ready to take a strenuous physical training test.  MEB initiation was recommended since it would take 1-2 years before the CI could “successfully endure the life style in the Marine Corps.”  

The 22 October 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of left knee activity-related pain with feelings of instability.  Physical examination showed left knee with flexion to 135 degrees and hyperextension to -5 degrees with no mention of painful motion.  The CI had a 1+ Lachman and 1+ anterior drawer with very good endpoint.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis).  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 history of surgery to remove a meniscus (5259) to support a rating under those codes.  There was no fracture, nonunion 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 evidence of a slight impairment of the knee (instability) to support a 10% rating using code 5257, and there was also evidence of moderate impairment of the muscles responsible for extension of the knee to support a 10% rating using code 5314 (group XIV muscle dysfunction).  Neither constituted a rating advantage for the CI and panel members noted that combining those ratings would violate VASRD §4.14, avoidance of pyramiding, the evaluation of the same disability under various diagnoses.  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 left knee condition.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150610, w/atchs
Exhibit B.  Service 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:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC