RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03824 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20060131

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Rifleman, medically separated for “major depressive disorder (MDD),” “recalcitrant left anterior knee pain with tight hamstrings,” and “generalized anxiety disorder (GAD),” rated for overall effect, with a combined disability rating of 0%.

CI CONTENTION: No specific contention was made. 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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20051208	VARD - 20060517	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD	
Overall Effect	
0%	Attention Deficit Hyperactive
Disorder, Depressive Disorder and Anxiety Disorder	9434	NSC	20060320	
GAD							
Recalcitrant Left Anterior Knee Pain with Tight Hamstrings			Residuals, Status Post Left Knee Arthroscopy For Patella Subluxation	5257	10%	20060320	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

MDD, GAD, Recalcitrant Left Anterior Knee Pain with Tight Hamstrings. The PEB determined that the CI was unfit due to the “overall effect” of multiple conditions. In an “overall effect” case, each condition has been determined by the PEB to be separately not unfit, but the “overall effect” considered together creates a condition of unfitness. Such cases are identified by the PEB explicitly stating the conditions were combined under the provisions of “Overall Effect” and citing the SECNAVINST 1850.4E. The panel noted that this is also IAW Do DI 1332.38 E3.P3.4.4. In these cases, the panel evaluates each condition separately for fitness, but does not recommend a rating unless a preponderance of evidence demonstrates that a specific condition was separately unfitting at separation.

MDD and GAD. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s depressive condition began prior to service. He described a history of generalized distress reflecting mixed symptoms of depression, a sense of tension anxiety, and feeling keyed up and on edge following simple daily routines. He also had longstanding sleep onset insomnia, poor interest, feelings of anhedonia, lack of energy, and fatigue throughout adolescence, and a history of ADHD at age 18 treated with Adderall, which he discontinued prior to enlistment. After deployment, he underwent counseling with a private provider as well as in the service. In August 2005, he had a psychological evaluation and testing and was found to have major depression without psychosis, generalized anxiety disorder, attention deficit hyperactivity disorder by history, and alcohol abuse by history in remission. His Global Assessment of Functioning (GAF) score was 40-60 (serious to moderate symptoms).

The 14 November 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of depression and anxiety. Mental status examination (MSE) showed appropriate adherence to military bearing and grooming standards. His speech had a regular rate and rhythm with normal prosody. Mood was improved. Affect was euthymic and full. Thought processes were linear, logical, and goal directed and thought content was appropriate to discussion without evidence of suicidal or homicidal ideation, preoccupation, or delusions. Perception was without reported auditory or visual hallucinations and he did not appear to be responding to internal stimuli. Judgment and insight were fair and impulse control was intact. Insight was deemed to be fair. His GAF score was 65-70 (some mild symptoms). The examiner indicated the CI’s psychiatric condition did not appear to impair his functioning within the military and he was considered psychiatrically fit for service.

At the 20 March 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported feeling depressed and anxious. He had a slow onset of symptoms, which became worse in June or July 2005. The MSE showed an alert, cooperative young man who was casually but appropriately dressed. There were no loosened associations, flight of ideas, bizarre motor movements, or tics. His mood was somewhat tense and his affect was appropriate. He stated he had nightmares and some intrusive thoughts, but had no homicidal or suicidal ideation or intent. There was no impairment of thought processes or communication and no delusions, hallucinations, ideas of reference, or suspiciousness. He was oriented times three. His remote and recent memory appeared to be good. Insight and judgment appeared to be adequate, as was his intellectual capacity. His GAF score was 55 (moderate symptoms). The examiner noted that although the CI had a combat tour and did witness and experience traumatic events, he did not meet all of the criteria for posttraumatic stress disorder (PTSD). At a clinic visit in May 2006 for purposes of a research study on post-deployment health, a clinical interview supported the diagnosis of PTSD related to combat, GAD, alcohol dependence and lifetime MDD.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MDD and GAD 0%, for overall effect. The VA rated the attention deficit hyperactive disorder, depressive disorder and anxiety disorder as not service connected, coded 9434 (MDD), based on the STR and C&P examination, citing the conditions existed prior to service and were not permanently worsened as a result of service. There was insufficient evidence to determine whether either the MDD or GAD were separately unfitting or were both in aggregate unfitting. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the MDD and GAD as not unfitting.

Recalcitrant Left Anterior Knee Pain with Tight Hamstrings. According to the STR and MEB NARSUM, the CI’s left knee condition began in September 2004 while deployed when he felt a pop and had a questionable patellar subluxation, which did not require reduction. An MRI of the knee showed intact ligaments, including the patellofemoral ligament, and no patellar fracture or osteochondral defect. There was edema in the tissues anterior to the patella and a question of

some laxity of the medial patella retinaculum. A first limited duty (LIMDU) was issued on 19 May 2005 for dislocation of the patella and patellar insufficiency.

At an orthopedic clinic visit on 25 July 2005, examination of the left knee revealed a range of motion (ROM) of 13-145 degrees (normal 0-140). The knee was able to be brought to full extension but had an extension lag. There was tenderness of the patella tendon and patellar crepitus (grinding sensation). With patella compression, there was guarding and re-creation of pain as well as patella apprehension. There was pain with medial and lateral glides of the patella, but negative with a patella tilt. There was no laxity, no instability and no evidence of a meniscal tear. X-rays of the left knee were read by a radiologist as normal, but an orthopedic surgeon interpreted the findings as some lateral tilt of the patella with a normal lateral condyle.

Duty limitations on 29 March 2005 included no daily physical therapy (PT) with the unit, running at his own pace, field duty for administrative purposes only, no forced marches and no watch standing or guard duty. Another LIMDU was issued on 5 October 2005 for left anterior knee pain and left hamstring contracture. Despite PT, he continued to experience pain and have objective evidence of tight hamstrings. The non-medical assessment (NMA) on 5 October 2005 indicated the CI was not world-wide deployable and could not perform a physical fitness test.

The 5 October 2005 MEB NARSUM examination, 3 months prior to separation, noted the complaint of left anterior knee pain. Physical examination showed minimal quadriceps atrophy of the left lower extremity. The ROM was 0-135 degrees. Patellar tracking was normal. There was no instability, laxity, or joint line tenderness, and no evidence of a meniscal tear, but he had positive quadriceps inhibition, which created the feeling of pain and questionable instability. The hamstrings were tight. During the 17 October 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported knee pain and a dislocating patella. Physical examination revealed mild quad atrophy, normal patellar tracking, and pain with flexion and extension.

At a VA clinic visit on 27 January 2006, the CI reported he re-injured his knee one day earlier while attempting to lift a heavy object and felt like the knee popped out and spontaneously went back in place. X-rays of the left knee in January 2006 were normal. At the VA C&P examination, 2 months after separation, the CI reported an apparent left patella dislocation while deployed, which he indicated was reduced by a corpsman, with residual left knee pain and intermittent swelling. He did not use crutches, a brace or a cane. Physical examination showed left knee ROM 0-145 degrees. He could do a knee bend about half the way down. There was no tightness of the hamstring muscles. The left patella did not have a smooth glide as did the right, but the knee was stable, although the CI felt a clicking sensation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left knee pain condition 0% for overall effect. The VA rated the residuals, status post left knee arthroscopy for patella subluxation condition 10%, coded 5257 (knee, other impairment), based on the C&P examination, citing recurrent subluxation or lateral instability of the knee which was slight. The panel determined that the left knee condition was separately unfitting based on the duty limitations, two LIMDU’s and the NMA. There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 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, there was evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45) based on pain with medial and lateral glides of the patella. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a

disability rating of 10% for the recalcitrant anterior left knee pain with tight hamstrings condition, coded 5099-5003.

BOARD FINDINGS: In the matter of the major depressive disorder and generalized anxiety disorder and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication as not separately unfitting conditions. In the matter of the recalcitrant left anterior knee pain with tight hamstrings condition, the panel recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Recalcitrant Left Anterior Knee Pain with Tight Hamstrings	5099-5003	10%	

DEPARTMENT OF THE NAVY
SECRETARY OF TIIE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO:
1850
CORB:003 12 Oct 20

From:	Director, Secretary of the Navy Council of Review Boards To:	
Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
Ref:	(a) DoDI 6040.44
(b) PDBR ltr of 23 Mar 20

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 7 October 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR. Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 0% to 10% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the office of the Deputy Commandant, Manpower and Reserve Affairs, for appropriate changes to your personnel records and notification to you upon completion.