RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02506
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20050628

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Field Radio Operator, medically separated for “patellar dislocation, chronic subluxation left knee” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that his left knee continues to be problematic and should have been rated higher than 0%.  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 - 20050628	VARD - 20111024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Patellar Dislocation, Chronic Subluxation Left Knee	5299-5003	0%	Left Knee Intermittent Patellar Subluxation with Patellofemoral Syndrome	5260	0%	20110723	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Patellar Dislocation, Chronic Subluxation Left Knee.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in November 2003 after falling and twisting his left knee while going up stairs.  In February 2004 the CI reported increased pain with exercise and his knee gave out with walking.  Magnetic resonance imaging (MRI) on 8 March 2004 demonstrated no evidence of tendinous, ligamentous, or meniscal tear; however a small area within the lateral femoral condylar epiphysis was possibly within normal limits of variation or a small area of a resolving bony contusion.  The CI was referred for physical therapy and was treated with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  There was only minimal and temporary relief of symptoms.  

At the 23 September 2004 orthopedic examination, the CI reported instability of the left knee and a feeling that it would dislocate.  On examination all major ligaments were intact, but his patella was high (alta) and “easily subluxed laterally without a definitive end point.”   Provocative tests to detect meniscal pathology were negative, but there was a deficit where the vastus medialis oblique (quad muscle responsible for knee stability) attached.  The examiner recommended medial reef surgery with lateral release to treat recurrent patellar dislocation.  On 2 December 2004 the CI reported he still had a problem with his left knee.  The patella was subluxable and the patellofemoral joint was painful.  On examination he had a rather deep clunk, which was a meniscus being trapped and pulled by the femoral condyle.  The examiner felt the CI likely had a bucket type meniscal tear as well.  The CI declined the surgery. 
 
During the 7 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the examiner recorded that the CI had a subluxable patella with locking and dislocation of the left knee since November 2003.  The CI reported left knee pain.  The physical examination showed a subluxable left patella and otherwise normal knee examination. 

The 18 January 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant 4/10 knee pain (10 being the worst pain) increasing to 10/10 with left knee dislocations, which occurred at least monthly.  The CI also reported left lower extremity weakness.   The physical examination showed a normal range of motion (ROM) in all extremities and normal muscle strength in all extremities.  All major ligaments of the left knee were intact and there was no effusion, but the examiner noted that the left patella was high and easily subluxed laterally.  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 0%, coded 5099-5003 (degenerative arthritis).  There was no evidence of painful motion with functional loss supporting a 10% rating (based on VASRD §4.59, §4.40 and §4.45).  There was likewise no limitation of motion which attained a 10% 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).  However, the CI not only had recurrent subluxation of the left knee both subjectively and objectively, but the PEB adjudicated the CI’s disability as patellar dislocation, chronic subluxation left knee.  Therefore, use of code 5257 (knee, other impairment of) is both reasonable and appropriate.  Members then discussed whether the condition was slight, moderate, or severe.  Clearly, with both subjective and objective findings with a failure of physical therapy to improve the condition and surgery recommended to ameliorate the condition, a 20% rating for a moderate disability is not unreasonable and is more consistent with his clinical course than 10% for a slight disability.  However, members were not convinced the condition was severe at the time of separation since the CI had a normal gait, a full ROM, cruciate and collateral ligaments were intact, and the CI elected not to proceed with surgery as was his right.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the patellar dislocation, chronic subluxation left knee condition, coded 5257.  

BOARD FINDINGS:  In the matter of the patellar dislocation, chronic subluxation left knee condition, the panel majority recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  The single voter for dissent recommends modification to 10% and elected not to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel majority 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	
Patellar Dislocation, Chronic Subluxation Left Knee	5237	20% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151029, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 22 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(m) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(n) PDBR ltr dtd 21 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(o) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX

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

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

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

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

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

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

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

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

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

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

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

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

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

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

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

     n. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXXX
	Acting