RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02260
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20040215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E5, Motor Transport Mechanic, medically separated for “chronic left patellar instability” rated 20%.

CI CONTENTION:  The CI contends his knee is getting worse and that he needs his teeth fixed.  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 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 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 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 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 - 20031201	VARD - 20040329	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic L Patellar Instability	5299-5003	20%	Chondromalacia…Instability	5003-5257	10%	20031218	
Status Post…Patellar Realignment Left Knee	Cat II	Residuals…Post-Op Left Knee	5259	10%		
		Scar, Left Knee	7804	0%		
…Chondromalacia…L Knee		No VA Entry	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Left Knee Instability.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent surgery in October 1999 for left knee instability, with hardware left in place for stabilization.  Chondromalacia of the patella (inflammation & softening of cartilage under the knee cap) was shaved, but no meniscal (semi-lunar) cartilage was removed in this operation.  The CI reinjured his knee and stated that the knee “gave out” while going over a wall on the obstacle course.  On examination, the knee was tender, but there was no swelling, reddening, or bruising.  Testing for ligamentous instability (varus & valgus) and cartilage damage (McMurray) was negative.  Full range of motion was recorded with “noticeable subluxating patella”.  The presence of crepitus was also reported.   At the 23 July 2003 orthopedic clinic appointment, 7 months prior to separation, the CI reported left knee pain, atrophy, swelling, and an inability to run.  He denied dislocations having occurred since the knee surgery.  On examination, the knee was stable but tender, with atrophy and mild effusion (excess fluid accumulation in or around the knee joint; also known as water on the knee) and severe crepitus (popping or grating noise or sensation of the joint during movement).  The patella (knee cap) deviated laterally at full extension of the leg (positive J sign), and testing for potential patellofemoral pain syndrome (PFPS) was positive.  Testing for ligamentous instability was negative, and the examiner indicated the knees were stable bilaterally.  ROM was recorded as 5-130 degrees (normal 0-140).  Radiographic studies indicated degenerative disc disease in the left knee, with the surgical hardware in good position.  At the 28 July 2003 MEB NARSUM examination 5 days later, the CI reported persistent left knee pain with a chronic sensation of instability in the joint, though he again denied dislocation or subluxation (temporary dislocation).  At the 18 December 2003 Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported the left knee “always tends to be sore and it tends to swell.”  He reported an inability to run or do any marching due to the left knee condition.  Physical examination showed normal gait and stance, with an inability to hop on his left due to pain and instability.  The CI was also able to do a partial squat, but complained of significant discomfort in the left knee with the maneuver.  Neurological examination was normal.  There was no swelling but considerable crepitus reported.  Flexion ROM was recorded as 0-140 degrees (normal 0-140), with pain at full flexion.  His extension was limited to -10 degrees from full extension again with pain. Testing for ligament instability was negative, as was evaluation for cartilage damage (negative McMurray).  The left knee was additionally limited by pain, but not by fatigue, weakness, lack of endurance, or incoordination.  Radiographic study revealed the post-surgical hardware in place, but an otherwise normal left knee.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 20%, coded 5299-5003 (analogous to degenerative arthritis).  The VA rated the left knee condition 10%, coded 5003-5257 (degenerative arthritis – knee, other impairment of subluxation or instability), and also rated the left knee 10%, coded 5259 (removal of symptomatic semilunar cartilage).  The VA additionally rated the left knee surgical scar 0%, coded 7804 (scar, unstable or painful).  There was evidence of moderate subluxation to support a 20% rating under the 5257 code (knee, other impairment of).  There was no evidence of severe subluxation or lateral instability to support a higher 30% rating under the 5257.  There was no limitation of flexion to support a rating under 5260, no history of surgery to remove a meniscus (5259), and no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  However there was evidence of limited extension with pain to justify a 10% rating under code 5261 (Leg, limitation of extension of).  Finally, 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).  No additional functional limitation was evidenced by the examinations.  The panel does not recommend disability rating for scars unless their presence imposes a direct functional limitation that renders the CI unfit.  The knee scar did not interfere with wear of military gear and was not painful at the MEB examination.  Any contribution from the scar on ROM limitation was addressed above.  There was insufficient evidence of duty-limiting impairment from the knee scar, thus the panel concluded that the scar condition could not be recommended for additional disability rating.  The panel agreed that the two additional diagnoses determined to be Category II conditions (conditions which contributed to the primary unfitting condition but were not separately ratable) were intertwined diagnoses, and the overall knee impairment from all listed diagnoses was subsumed under the ratings for the knee by both the PEB and the VA.  More than one rating based on the same impairment is prohibited, IAW VASRD §4.14 (avoidance of pyramiding).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the chronic left knee subluxation, coded 5257 and a rating of 10% for left knee limitation of extension coded 5261.  This does not violate the VA policy of pyramiding in that unrelated knee conditions on the same knee can be separately rated.

BOARD FINDINGS:  In the matter of the chronic left patellar instability condition, the panel unanimously recommends a disability rating of 20%, coded 5257 IAW VASRD §4.71a.  In the matter of the chronic left patellar instability condition, the panel unanimously recommends a disability rating of 10%, coded 5261 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Subluxation-Moderate	5257	20%	
Left Knee Limitation of Extension	5261	10%  	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150819, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(c) PDBR ltr dtd 06 Jul 17 XXXXXXXXXXXXXXXXXX
  
	(d) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(e) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(f) PDBR ltr dtd 07 Jul 17 XXXXXXXXXXXXXXXXXX

	(g) PDBR ltr dtd 02 Aug 17 XXXXXXXXXXXXXXXXXX

	(h) PDBR ltr dtd 06 Jul 17 XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (h) are approved.  The official records of the following individuals are to be corrected as follows:

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

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 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 USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge. 

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

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

     g. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.       
     
3.  Please take action to implement these decisions.

XXXXXXXXXXXXXXXXXX