RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00396
BRANCH OF SERVICE:  Marine Corps	SEPARATION DATE:  20020215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Marine, medically separated for “multiple injuries right knee” with a disability rating of 20%.

CI CONTENTION:  The CI made lengthy contention that included her left and right knee, lower back pain, left and right foot, left and right ankle, OCD, bi-polar, depression, anxiety.  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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20011213	VARD - 20020806	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multiple Right Knee Injuries	5257	20%	Right Knee Meniscus Tear	5299-5261	20%	20020531	
Suspicion for Microfractures involving the Proximal Tibial and Lateral Femoral Condyle	Category II	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Multiple Injuries Right Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in August 2001 during Basic Training as a result of a twisting injury.  A magnetic resonance imaging (MRI) demonstrated a tear of the medial meniscus (knee cartilage), partial tears of the medial and lateral collateral ligaments (MCL and LCL), and a tear of the middle part of the anterior cruciate ligament (ACL).  There was also evidence of possible trabecular microfractures (“bone bruise”) in the proximal tibia and lateral femoral condyle adjacent to the knee.

At the initial available evaluation on 20 August 2001, 2 weeks after an initial injury and 2 days after a re-injury, the CI presented with a knee immobilizer.  She complained of 4/10 right knee pain that worsened during knee flexion.  She denied locking of the knee.  During a clinic follow-up one week later the CI reported that bending the knee caused pain.  Despite stating that there was no pain with walking or weight-bearing, examination showed an antalgic gait.  Passive flexion of the knee caused pain.  There was evidence of ACL laxity (Lachman test) but with an endpoint suggesting that a complete tear was not present.  There was also some laxity of the MCL.

The CI was evaluated in the orthopedic clinic on 29 August 2001, but there is no corresponding STR entry in evidence.  However, according to the MEB NARSUM 2 weeks later, examination at that time showed evidence of ACL injury (positive Lachman and anterior drawer tests), but the degree of ligament laxity was not reported.  The medial and lateral collateral ligaments “seemed to hold well,” indicating the MCL and LCL were stable.  Range of motion (ROM) testing showed flexion of 95 degrees (normal 140) and extension limited by 20 degrees (normal 0).  Because of limited motion, testing of the menisci could not be accomplished.  The examiner concluded that operative treatment was required.  At the 24 October 2001 MEB examination (recorded on Standard Forms 88 and 93), 4 months prior to separation, decreased and painful right knee ROM was noted, in addition to mild swelling.  The examiner indicated that the CI was being separated “with surgery and rehab pending.”

At the 31 May 2002 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported she was receiving no current treatment.  Physical examination showed a “good posture and gait.”  Right knee flexion was 102 degrees and extension 12 degrees.  There was no swelling or tenderness, but painful motion was not mentioned.  A mechanical aid was not being used.  One test for ACL instability (Lachman) was negative and one test for possible meniscal damage was negative (McMurray).  A pre-operative orthopedic evaluation 15 months after separation characterized the ACL instability as “mild.”  

In June 2003, 16 months after separation, the CI underwent arthroscopic surgery of the right knee.  Findings at that time included “pathologic laxity” of the ACL further described as “partial disruption but still some halfway decent remaining continuity to the ligament.”  The ACL laxity was addressed with thermal shrinkage, and reconstruction was not required.  The large medial meniscal tear was noted, in addition to meniscal degeneration as a result of chronic displacement and pressure.  The meniscus was not repairable and subtotal excision was required.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 20%, coded 5257 (knee, other impairment).  The PEB adjudication included the ACL tear, medial meniscus tear and partial tear of the LCL.  The PEB also determined that proximal tibial and lateral femoral condyle microfractures were Category II conditions (conditions that contribute to the primary unfitting condition but are not separately ratable).  The VA also rated the right knee condition 20%, but used an analogous 5261 code (leg, limitation of extension), citing limitation of extension as the rationale.  

Under the PEB’s coding approach, a 10% rating is warranted for “slight” and 20% for “moderate” subluxation or instability.  The panel agreed that the instability component of the knee injury was best characterized as “slight” therefore a 10% rating was supported.  The panel considered other routes to rating.  The panel agreed that the meniscal tear, which the PEB also included under the 5257 code and may have been responsible for 10% of their rating, would have rendered the CI unfit as a stand-alone injury separate from the ACL injury, and thus warranted consideration for dual coding.  The meniscal tear was manifested by pain and limited motion, but there were no documented episodes of frequent knee locking with recurrent effusions to justify rating under the 5258 code.  However, there was sufficient evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  

There was no loss of flexion sufficient to warrant a rating under the 5260 code, but a rating for limitation of extension was also considered.  The orthopedic examination performed soon after the injury noted extension limited by 20 degrees.  However, it was agreed that the VA examination 9 months after the injury more accurately reflected stable, functional ROM since knee swelling was now resolved.  Although it noted extension limited by 12 degrees, this degree of limitation was not functionally consistent with the normal gait documented by the same examiner.  The panel thus concluded that additional rating for limited extension was not supported.  Therefore, an outcome more favorable to the CI was not available via a dual-coding approach, since the only justified avenue (10% for instability plus 10% for painful motion) still resulted in a 20% rating.  

Finally, the PEB listed the micro-fractures of proximal tibial and lateral femoral condyle as related diagnoses (Category II) that contributed to the disability in this case.  The panel agreed that these were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  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 multiple right knee injuries condition.

BOARD FINDINGS:  In the matter of the multiple right knee injuries condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20160615, w/attachments
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:

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