RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2012-01851
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20141216
SEPARATION DATE:  20030731

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty LCpl/E-3 (2131/Towed Artillery Systems Technician) medically separated for right knee chondromalacia (damage to cartilage under the kneecap).  This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or physical fitness standards.  The CI was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The right knee condition, characterized as “Grade IV chondromalacia patella of right patella,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (status post [s/p] surgical debridement, right quadriceps tendinosis) for PEB adjudication.  The PEB adjudicated “Grade IV chondromalacia patella of right patella” as unfitting, rated 10%.  The remaining condition was adjudicated as Category II (conditions that contribute to the unfitting conditions).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I have had 2 more surgeries since exit of USMC, still wear brace on knee.”  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting (and Category II) right knee condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Board for Correction of Naval Records.

The Board acknowledges the CI’s contention regarding the significant impairment his service-connected condition continues to impose, but must emphasize that the Disability Evaluation System has neither the role nor authority to compensate for later severity or complications of conditions that resulted in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  Post-separation evidence is probative to the Board’s recommendations only to the extent it reasonably reflects the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20030520	VA - (1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Grade IV Chondromalacia Patella of Right Patella	5099-5003	10%	Residuals, R Knee Chondromalacia With Quadriceps Tendinosis	5099-5019	10%	20030627	
S/P Surgical Debridement, Right Quadriceps Tendinosis	Category II					
		Scar, Right Knee	7805	0%	20030627	
No Additional MEB/PEB Entries in Scope	No Other VA Conditions in Scope	
Combined:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20030805.

ANALYSIS SUMMARY:  

Right Knee Condition.  The record indicated the CI had a painful right knee beginning in 2001.  He underwent multiple surgeries to include excision of chronic infected tissue and debridement of quadriceps tendinosis (the area above the knee) 2 years prior to separation.  After the surgeries, the CI had persistent pain in the right knee with intermittent swelling especially at the end of the day.  He also had cracking and popping in the knee without any frank episodes of locking, was unable to run, and had pain with prolonged walking or standing or repetitive use.  Imaging (magnetic resonance imaging) 6 months prior to separation showed an effusion in the joint, normal cartilage (menisci), and progression of his previous chondromalacia on the patella down to bone (classified as Grade IV).

In the Report of the Medical Board examination 5 months prior to separation, there was mild effusion of the right knee, moderate crepitus (sensation of grating) on the right patella (kneecap).  The range-of-motion (ROMs) of the knees were 0 to 120 degrees on the right (normal 0 to 140 degrees) and 0 to 130 degrees on the left (which was also noted to have mild crepitation).  Both knees were stable with no laxity on examination and the right knee had a well-healed surgical scar.  At the MEB exam 3 months prior to separation, the CI had numbness over the patella (kneecap), no tenderness to palpation, small effusion in the knee, no crepitus (grating sound or feeling) and pain with full flexion and extension.

At the VA Compensation and Pension (C&P) exam (a month prior to separation), the CI was walking with a brace and had a limp of the right leg.  He was unable to hop on either leg or perform squatting maneuvers because of pain and stiffness in the joint.  He had slight generalized swelling of the right knee, mild tenderness in the suprapatellar area (proximal to the kneecap), “some mild pain at the limit of his flexion,” and ROM of 0 to 100 degrees (normal 0 to 140 degrees) which was “additionally limited by pain but not by fatigue, weakness, lack of endurance, or incoordination.”

In a follow-up C&P exam almost 4 years after separation, the CI reported that his knee had gotten worse and he had daily constant pain, which got worse after standing at work during the day.  He noted stiffness, instability, reduced endurance, difficulty weight-bearing and clicking and popping in his knee.  He was able to walk about an hour before the pain forced him to sit and rest, and was wearing a knee brace.  Follow-up C&P exams and VARDs reported further disability of the right knee and requirement for further surgery.  The VA rated the knee with a temporary 100% (convalescent) rating following surgeries (beginning in May 2008), with a final permanent 30% rating that included knee instability.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB found the CI’s unfitting condition to be “grade IV chondromalacia patella of right patella” and that “status post surgical debridement, right quadriceps tendinosis” contributed to the unfitting condition.  The PEB rated the knee condition at 10% under code 5299-5003 (Arthritis, degenerative, [hypertrophic or osteoarthritis]).  The VA characterized the condition as “Residuals right knee chondromalacia with quadriceps tendinosis” and rated it at 10% coded 5099-5019 (Bursitis).  VASRD §4.71a states that codes 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, so that codes 5003 and 5019 are effectively rated with the same criteria.

The Board determined that potential codes for the right knee condition could include 5014 (Osteomalacia) or 5024 (Tenosynovitis), but that these would be rated under the same criteria as either code 5003 or 5019 under §4.71a at 10%.  The Board considered whether a higher combined rating might be indicated under any other codes for the right knee condition but a higher evaluation of 20% is not warranted unless there is moderate subluxation or lateral instability of the knee (code 5257), flexion limited to 30 degrees (code 5260), or extension limited to 15 degrees (code 5261).  There was no objective instability at the time of separation for possible dual rating, and there was insufficient evidence of tibial pathology for alternative coding under 5262, or meniscal surgery for alternative coding under 5258 (dislocation of the semilunar cartilage with locking pain and effusion into the joint).  The Board noted the surgeries and higher VA rating multiple years after separation and adjudged this was due to post-separation worsening and not indicative of the CI’s disability picture at the time of separation.

Ideal coding would be analogous to code 5014 at 10%; however, this would not result in a change of rating or be of any benefit to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition (incorporating both the chondromalacia of the knee and the quadriceps tendinosis).

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends no re-characterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120806, w/atchs
Exhibit B.  Service Treatment Record (in part)
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 22 Apr 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, 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:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXX
	     				  Assistant General Counsel
		  (Manpower & Reserve Affairs)