RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02152
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20041231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Tactical Network Specialist, medically separated for “bilateral knee pain and swelling,” rated 10% for each knee, with a combined disability rating of 20%.  

CI CONTENTION:  “New info about diagnosis.” [Sic]  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 - 20041012	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain and Swelling	5099-5003	10%	No VA Exam in Evidence	
	5099-5003	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Knee Pain and Swelling.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee condition began gradually in September 2003 without specific injury or trauma.  Initial X-rays were normal and there was no surgical indication.  

At the 23 March 2004 civilian neurology evaluation, 9 months before separation, the CI complained of wasting of muscles around the knees and below as well as distally in the hands in addition to his bilateral knee pain.  He also reported pain in his shoulders, back and hips.  The CI noted that his mother had similar symptoms.  The examiner indicated that the CI had muscle wasting from approximately two thirds of the way down below the thigh downwards as well as distally at the wrist and hands.  He also noted the CI had developed spasms in the left thigh and curling of the right toe.  He was able to walk with a cane and bilateral knee braces.  The CI had undergone physical and steroid therapy, and he had been evaluated by orthopedics, rheumatology, primary care and a physiatrist.  Physical examination revealed the CI had inverted flask or inverted stork deformity of the lower extremity with wasting of the muscles starting two thirds of the ways down the thigh all the way down the calf and the foot and less through the distal portion of the wrist and hands.  He also noted the CI had glove-stocking hypesthesia (abnormal sensation), and his nerves appeared to be thickened.  There was marked weakness around the knee and distal muscles, and proximal muscles were intact.  The neurologist’s final clinical impression was that “the patient most likely has Charcot-Marie-Tooth disease” (hereditary motor and sensory neuropathy).  

The 24 March 2004 total body bone scan, 9 months before separation, revealed a mild increased tracer seen at both patellas and at the anterior tibial tubercles, but the areas of increased tracer were bilaterally symmetrical and were not felt to be of clinical concern.  The 3 April 2004 electrodiagnostic testing (NCV/EMG) was essentially normal with no electrodiagnostic evidence suggestive of neuropathy.  

At the 25 May 2004 neurology examination (by the Head, Division of Neurology), and the same neurologist’s 8 June 2004 NARSUM examination, approximately 7 months prior to separation, the CI reported an eight month history of bilateral knee pain and swelling.  There had been had persistent and steadily worsening left greater than right knee pain with waxing/waning swelling as well as a three to four month history of bilateral hand pain and one month of left shoulder pain.  Knee pain had recently been “so severe as to force him not to bend at the knees when walking, standing or sitting.”  The CI denied any bulbar symptoms, bladder dysfunction, overt weakness or significant trauma.  

The CI had a recent Rheumatologic evaluation and there was not enough evidence to render a diagnosis.  Orthopedic Surgery evaluation also indicated no clear diagnosis.  A civilian neurologists’ evaluation preliminarily diagnosed Charcot-Marie-tooth disease, but electrodiagnostic (NCV/EMG) studies as well as genetic testing were normal.  

On physical examinations, the CI walked stiff-legged with a cane but with normal base and camber.  The CI’s bilateral knees were tender with mild (left greater than right) swelling.  All joints had full ROM and there was normal motor strength (5/5) “[with] (some splinting that resolves with encouragement/challenge).”  Reflexes were normal and symmetric.  The neurologist’s impression was “multiple arthralgias worst at knees without any evidence of an ongoing neurologic condition … (and that it was) most likely a Rheumatological condition.”  

During the 20 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported swollen knees, wearing knee braces during the day, and joint pain in knees, ankles, wrists, shoulder, and upper back.  Physical examination showed knee effusions with tenderness.  

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 disability description combined the right knee and left knee conditions; however, the PEB clearly indicated each knee was coded 5099- 5003 (arthritis) and each knee was rated 10%, with application of the bilateral factor, resulting in a combined 20% rating.  Therefore the panel determined that the PEB found each knee separately unfitting and separately rated them as such.  The single VA disability rating in evidence was a 19 August 2004 decision indicating that vocational rehabilitation was not established for bilateral knee pain and swelling condition (NSC;  5299-5262 [tibia and fibula impairment]), citing a finding of pain without a finding of an underlying condition.  

There was no significant difference between the knees regarding rating considerations.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for either knee.  There was some functional limitation from each knee evidenced by the STR examinations.  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 that 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).  

The panel considered potential analogous rating as an active rheumatologic condition under code 5002 (arthritis rheumatoid (atrophic) as an active process), however there was insufficient pre-separation evidence of “symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year” to support the next higher rating above the PEB-awarded 20% combined rating.  There was no evidence of muscle injury no diagnosed neurologic disease for alternative rating under VASRD §4.71a (schedule of ratings—musculoskeletal system) or §4.124a (schedule of ratings—neurological conditions and convulsive disorders).  There was therefore no VASRD route to a rating higher than the combined 20% rating 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 bilateral knee pain and swelling condition.  

BOARD FINDINGS:  In the matter of the bilateral knee pain and swelling 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 20150806, 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 USMC
		- XXXXXXXXXXXXXXXXXX, USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
	 	- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC

		
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