RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-04099 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20081030

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Aircraft Rescue and Firefighting Specialist, medically separated for “status post [S/P] left anterior cruciate ligament [ACL] reconstruction” with a disability rating of 10%.

CI CONTENTION: Review requested of the knees, right hip, and back. 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’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20080724	VARD - 20090130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
S/P Left ACL Reconstruction	5299-5003	10%	S/P Left Knee ACL Reconstruction	5099-5010	10%	20081119	
Compensatory Pain in Right Hip, Right Knee and Lower Back	
Cat II	Right Knee Patellofemoral Syndrome	5099-5014	10%	20081119	
		Right Hip Bursitis	5019	10%	20081119	
		Degenerative Disc Disease T12-L1 and L5-S1, S/P Laminectomy	5243	10%	20081119	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Left Knee ACL Reconstruction. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in January 2007, when his left foot became stuck in the mud while running and he suffered a hyperextension injury (although

years earlier he underwent an ACL repair). Left knee X-rays showed no acute bony deformity, but an MRI on 9 February 2007 demonstrated a near complete ACL tear, grade 1 patellar chondromalacia, and patellar tendon enthesopathy (disorder involving the attachment of a tendon or ligament to a bone). On 22 May 2007 he underwent an ACL reconstruction followed by postoperative physical therapy (PT).

At an orthopedic visit on 18 October 2007, left knee motion was normal without effusion or instability, but the CI complained of right hip, right knee and low back pain, which was worse with running. At 6 months post-surgery, he was doing well, but complained of continued back pain. During a PT appointment on 20 December 2007, he reported a little pain in the left knee with activity, but ROM measurements were normal. In May 2008, he reported continued bilateral knee pain (rated at 2/10) with running, worse on the left than the right.

The 21 May 2008 MEB NARSUM examination, 5 months prior to separation, noted CI complaints of knee pain and instability. Physical examination showed a non-antalgic gait, and a single leg stance was minimally impaired on the left compared to the right. The left knee was non-tender and the range of motion (ROM) was 0-130 degrees (normal 0-140) compared to the right, which had 5 degrees of hyperextension to 140 degrees flexion. There was no effusion of either knee. Lachman’s testing (to determine instability) was 1+ with a firm end point on the left and no pivot shift. During a PT evaluation on 14 July 2008, 3 months before separation, left knee ROM was 0- 130 degrees, with pain and the right knee ROM was 0-133 degrees, with pain.

At the 19 November 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported occasional left knee pain, morning stiffness, decreased strength, and swelling after participating in sports; he used a left knee brace during athletic activities. Physical examination showed bumps consistent with Osgood-Schlatter’s disease, but no crepitation, instability, or patellar, meniscus, tendon, or bursae abnormalities. Left knee ROM was 0-127 degrees, with painful motion, but no ROM loss with repetition. An X-ray showed maintained medial and lateral joint compartments and no significant arthritic change or joint effusion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left knee condition 10%, analogously coded 5299-5003 (arthritis, degenerative). The VA also rated the left knee condition 10%, but analogously coded 5099-5010 (traumatic arthritis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints. Panel members agreed there no limitation of flexion or extension (5260 or 5261) for a compensable rating, however, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45). Additionally, there was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); history of surgery to remove a meniscus (5259); or 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). There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code. 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 left knee condition.

Contended Conditions: Compensatory Pain in the Right Hip, Right Knee and Lower Back: The panel’s main charge is to assess the fairness of the PEB’s determination that the contended Category II (contribute to the primary unfitting condition but not separately ratable) conditions were not unfitting. These conditions were not noted on limited duty forms, but were implicated in the second of two non-medical assessments. The panel’s first charge is to assess whether any of these conditions can be reasonably justified as separately unfitting for rating consideration. The panel’s threshold for such determinations is reasonably unfitting and remains adherent to the DoDI 6040.44 “fair and equitable” standard.

As noted above, the CI had a left knee ACL reconstruction on 22 May 2007.
Right Hip Pain. At the orthopedic visit on 18 October 2007, the CI reported right hip pain worsened by running. On examination, there was greater trochanteric bursa tenderness, but hip motion was normal and pain-free. On 4 November 2007, the CI sustained an injury to the right femur when “jaws of life” equipment hit him while he was working on a door. Right femur and knee X-rays showed normal bone mineralization and alignment, and no fracture or subluxation. Examination revealed right thigh tenderness laterally with mild ecchymosis. The diagnosis was a right thigh contusion and treatment consisted of a nonsteroidal anti-inflammatory drug, a narcotic/pain reliever combination, and crutches. The NARSUM indicated the blow exacerbated the hip pain, which was treated by PT as trochanteric bursitis and a thigh contusion. The right hip condition gradually resolved, although the CI noted some intermittent pain. At the C&P examination, the CI reported right hip stiffness, tenderness and occasional pain, and the examiner noted tenderness over the right trochanter. Hip flexion was 0-97 degrees (normal 0- 125) on the right, with painful motion, and 0-98 degrees on the left. The remainder of the hip motions were bilaterally symmetrical and there was no loss of motion with repetition. There was subjective weakness on the right, although objective hip strength was normal.

Panel members agreed that the subsumed Category II right hip pain was not reasonably justified as separately unfitting, as the right hip condition resolved with only intermittent pain and tenderness, bilaterally symmetric ROM measurements, and unremarkable X-rays. There was no performance-based evidence from the record that the right hip pain significantly interfered with satisfactory duty performance at separation. After due deliberation, considering all 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 right hip condition, and therefore no additional rating is recommended.

Right Knee Pain. At the October 2007 orthopedic consult, the CI reported right knee pain worsened by running. On examination, there was no effusion, and knee motion was normal with no pain. After the November 2007 injury mentioned above, a right knee X-ray demonstrated prominence of the medial joint line, suggesting a potential medial collateral ligament strain. No acute osseous abnormalities were identified, and examination revealed right knee and joint line tenderness, but no instability or laxity. The diagnosis was right medial collateral ligament strain and treatment included pain medications and crutches. The NARSUM noted complaints of some right knee pain and crepitation. The right knee had 5 degrees of hyperextension to 140 degrees of flexion but no effusion. The examiner noted patellofemoral crepitation along with a positive patellofemoral compression test, and tenderness on both the medial and lateral patellar facets. At the VA C&P examination, the CI reported right knee pain and weakness because he favored the left knee after the ACL surgery. On examination, there were bumps consistent with Osgood- Schlatter’s disease, but no crepitation, instability, patellar or meniscus abnormality, or abnormal tendons or bursae. Right knee ROM was 0-127 degrees with pain, but no loss of motion after repetition; right knee X-rays were normal.

Panel members agreed that the subsumed right knee pain was reasonably justified as separately unfitting. The right knee bore the brunt of the CI’s favoring of the left knee after surgery and rehabilitation, and as a result, he could not perform his military specialty duties due to patellofemoral deficits and pain. Although right knee ROM measurements were within normal limits, painful motion was documented at the VA examination. 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 right knee condition, coded 5099-5003.

Lower Back Pain. At a 10 December 2004 primary care visit, the CI complained of low back pain radiating to the legs with numbness and tingling down the right leg for about 1 month. He had a fusion of L5-S1 in 2002 and denied any recent back trauma, but had been doing a lot of moving in the prior week. On examination, there was tenderness of lumber spine and over the right

sacroiliac joint, and he was prescribed pain medication. At a PT visit on 9 October 2007, the CI reported low back pain, and at the October 2007 orthopedic consult, he stated his back pain was worse with running. The NARSUM documented intermittent low back pain, and PT ROM measurements on 14 July 2008 showed flexion to 90 degrees (normal) and a combined ROM of 210 degrees (normal 240), with an assessment of mechanical back pain. The provider noted that extension was very limited and there was a compensatory thoracic kyphosis, which contributed to the overall decrease in motion. At the C&P examination, the CI reported a history of back surgery in 2002 and back pain and numbness in the legs after he injured his knee in 2007. He had no bowel or bladder symptoms and no incapacitating episodes. The examiner documented a normal gait and flattening of the lumbar curvature. Measured ROM showed flexion to 85 degrees and a combined ROM of 215 degrees, with pain, but no loss of motion with repetition. An X-ray showed rods secondary to the prior lumbar discectomy in place with mild L4-L5 disc interval narrowing, but no acute abnormality.

The panel majority agreed that the subsumed low back pain was reasonably justified as separately unfitting. The CI had a fusion several years earlier and as a result of the rehabilitation process for the left knee, post-ACL reconstruction, he exacerbated his back condition and had pain with running. Although ROM measurements were within normal limits, there was painful motion, and he was thus limited in performing his military duties. The minority voter, adjudged that there was insufficient evidence to support the compensatory pain in the lower back as a separately unfitting condition, and instead favored it to remain as a Category II condition, not necessarily contributing to the left knee pain, but related to or caused by the left knee pain. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the low back condition, coded 5099- 5003.

BOARD FINDINGS: In the matter of the left knee condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication. In the matter of the right hip condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the right knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the back condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a The single voter for dissent recommends no change to the back condition and did not elect to submit a minority opinion. 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Status Post Left ACL Reconstruction	5099-5003	10%	
Compensatory Pain Right Knee	5099-5003	10%	
Compensatory Pain Lower Back	5099-5003	10%	
	COMBINED w/BLF	30%	

DEPARTMENT OF THE NAVY
SECRETARY OF THE 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: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
(a) DoDI 6040.44
(b)	PDBR ltr of 26 Jul 19
(b)	

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

2.	On 5 October 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 10 to 30 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the Office of the Deputy Commandant (Manpower and Reserve Affairs), for correction of your records as stated above.	You will be notified once those changes are complete.