RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX    BRANCH OF SERVICE:  Marine corpS
CASE NUMBER:  PD1100006                 SEPARATION DATE:  20080131
BOARD DATE:  20120202


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI)  was  a  Reserve  Cpl/E-4  (0331,
Machine Gunner)  medically  separated  for  status  post  (s/p)  right  knee
anterior cruciate ligament (ACL) reconstruction.  He was  treated,  but  did
not respond  adequately  to  fully  perform  his  military  duties  or  meet
physical fitness standards.  He underwent a Medical Evaluation Board  (MEB).
 Four knee conditions (right knee pain, s/p ACL reconstruction  right  knee,
s/p medial meniscus repair right knee, and s/p left knee  arthroscopy)  were
forwarded to the Physical Evaluation Board (PEB) as  medically  unacceptable
IAW SECNAVINST 1850.4E.  The PEB found  the  s/p  ACL  reconstruction  right
knee unfitting, and rated it 10% IAW the Veterans’  Administration  Schedule
for Rating Disabilities (VASRD). Persistent right knee pain  and  s/p  right
knee medial meniscus (MM)  repair  were  both  adjudicated  as  Category  II
(related to the unfitting right knee condition).  The  left  knee  condition
(s/p left knee arthroscopy) was adjudicated as Category III (not  separately
unfitting and not contributing to the unfitting right knee condition).   The
CI made no appeals, and was thus medically  separated  with  10%  disability
IAW applicable Navy and DoD regulations.


CI CONTENTION:  The CI states, “Pain on both my knees have  increased  while
performing physical activities like walking or standing  for  short  periods
of times.  My limitations are greater now because of the pain.   Right  knee
gives out and are unable to stand  on  it  unless  I  stretch  it  prior  to
moving.  More grinding on both knees when squatting down or walking  up/down
on stairs which also creates pain.”


RATING COMPARISON:
|Navy PEB – dated 20071202      |VA (4 mo. Pre Separation) – All Effective |
|                               |20080201                                  |
|Condition                      |Code                                      |



ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed by the  CI
regarding the significant impairment with which his condition  continues  to
burden  him.   The  Board  is  subject  to  the  same  laws  for  disability
entitlements as those under which the military Disability Evaluation  System
(DES) operates.   The  DES  has  neither  the  role  nor  the  authority  to
compensate service members for  anticipated  future  severity  or  potential
complications of conditions resulting in medical separation.  That role  and
authority is granted by Congress to  the  Department  of  Veterans’  Affairs
(DVA).  The Board’s authority resides in  evaluating  the  fairness  of  DES
fitness decisions and rating determinations at the time of  separation  from
service.

Right Knee Condition.  In February 2005, this Marine  sustained  a  twisting
injury of his right knee while he was deployed to Iraq.   When  he  returned
to the US, he was diagnosed with a torn ACL.  He  underwent  ACL  repair  in
July 2005.  In December 2005, he was still having problems  with  his  right
knee, and he was placed on limited duty (LIMDU).  In March  2007  he  had  a
right knee arthroscopy,  with  medial  meniscus  (MM)  repair.   During  the
procedure, it was noted that the ACL graft was intact.  His right knee  pain
persisted, and an MEB was initiated.  At  his  June  2007  MEB  exam,  seven
months prior to separation, the CI reported right knee pain,  and  inability
to run or perform field activities.  His gait was  normal.   Examination  of
the right knee  revealed  trace  effusion,  but  the  joint  was  stable  to
anterior, posterior, varus, and valgus  stress.   The  right  Lachman’s  was
equivocal, with 1-2 mm of motion but a firm and stable endpoint.  There  was
vague discomfort with palpation of the medial joint  line,  but  no  lateral
joint line tenderness.

Three months later, at his September 2007 VA Compensation and Pension  (C&P)
exam, the right knee showed no effusion, redness, heat,  abnormal  movement,
subluxation, or locking pain.  There was some mild soft tissue swelling  and
some crepitus was noted, but no instability.  McMurray’s  and  Drawer  tests
were normal bilaterally.  The patellofemoral compression test  was  positive
on the right.  Motor strength of the right lower extremity was 5 out  of  5.
Two goniometric range of motion (ROM)  evaluations  were  evident,  and  are
summarized below.

|Goniometric ROM   |MEB – 7 mo.      |C&P – 4 mo.       |
|Right Knee        |Pre-Sep          |Pre-Sep           |
|                  |(20070621)       |(20070918)        |
|Flexion (140⁰ is  |110⁰             |130⁰              |
|normal)           |                 |                  |
|Extension (0⁰ is  |0⁰               |0⁰                |
|normal)           |                 |                  |
|Comment           |No mention of    |Pain at 130⁰      |
|                  |pain             |flexion           |
|§4.71a Rating     |0%               |10%*              |


           *10% based on §4.40 (Functional loss), §4.45 (The joints), and
      §4.59 (Painful motion)

The Board carefully reviewed all  evidentiary  information  available.   The
PEB and the VA chose different coding options for the right knee  condition,
but both had assigned a rating of 10%.  The right knee limitation of  motion
was essentially non-compensable based on  VASRD  §4.71a  knee  and  leg  ROM
codes (5260 and 5261).  However, IAW VASRD §4.40, §4.45, and  §4.59;  a  10%
rating is warranted  when  there  is  satisfactory  evidence  of  functional
limitation due to painful motion of a major joint.  The CI clearly had  pain
with motion, as reported in  his  history  and  during  the  C&P  exam,  and
therefore  qualifies  for  a  10%  rating.   The  Board  then  directed  its
attention to the issue of ligamentous instability.  Review of the  treatment
record shows that at both the June 2007 MEB exam and the September 2007  C&P
exam, there  was  no  clear-cut,  objective  evidence  of  significant  knee
instability.  The only laxity noted on exam was an equivocal Lachman’s  sign
with 1-2 mm of motion but a firm and stable endpoint.  The Board  determined
that this was not sufficient evidence  of  joint  instability  and  was  not
unfitting, and therefore does not justify  a  separate  rating.   After  due
deliberation, and mindful  of  VASRD  §4.3  (Reasonable  doubt),  the  Board
unanimously recommends a rating of 10% for the right knee.

Left  Knee  Condition.   In  August  2006,  the  CI  underwent   left   knee
arthroscopy, and partial lateral meniscectomy.  The left  knee  surgery  was
considered a success.  Postoperatively, the CI was  seen  a  few  times  for
some left knee pain while running, but no specific diagnosis was  made.   At
his June 2007 MEB exam, he did not complain of left knee pain.   Examination
revealed no effusion, joint line tenderness  or  instability.   Furthermore,
the left knee condition was not mentioned  in  the  commander’s  non-medical
assessment (NMA).  At the September 2007 C&P exam, left  knee  ROM  was  135
degrees flexion and  0  degrees  extension,  without  pain.   There  was  no
instability, and left knee x-rays were normal.  In  October  2007,  exam  of
the left knee was reported as normal, with full ROM.   As  mentioned  above,
the Navy PEB adjudicated the left knee as Category  III.   The  Board  could
not find sufficient evidence that the left knee  condition  interfered  with
satisfactory  performance  of  required  military  duties.    All   evidence
considered, there was not reasonable doubt in the CI’s  favor  for  reversal
of the PEB’s fitness determination for the left knee condition.   The  Board
unanimously agrees that the left knee was  not  unfitting  at  the  time  of
separation from service.

Remaining   Conditions.    Hamstring   muscle   defect,    acne    vulgaris,
photorefractive keratectomy (PRK), and several other  conditions  were  also
noted  in  the  DES  file.   None  of  these  conditions   were   clinically
significant during the MEB/PEB period, none were the basis  for  LIMDU,  and
none were implicated in the NMA.  These conditions were all reviewed by  the
action officer and considered by the Board.  It  was  determined  that  none
could be argued as unfitting and subject to separation rating.   The  Board,
therefore,  has  no  reasonable  basis  for  recommending   any   additional
unfitting conditions for separation rating.


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.  In the matter of  the  right  knee  condition
and IAW VASRD  §4.40,  §4.45,  §4.59,  and  §4.71a;  the  Board  unanimously
recommends no change in the PEB adjudication.  In the  matter  of  the  left
knee condition, hamstring muscle defect, acne vulgaris, PRK,  or  any  other
conditions eligible for consideration; the Board unanimously agrees that  it
cannot recommend any findings of unfit for additional rating at separation.


RECOMMENDATION:  The Board, therefore, recommends that there be no
recharacterization of the CI’s disability and separation determination, as
follows:

|UNFITTING CONDITION                               |VASRD CODE  |RATING  |
|S/P Right Knee ACL Reconstruction, with Persistent|5299-5003   |10%     |
|Pain                                              |            |        |
|COMBINED    |10%     |


The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110104, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record




      XXXXXXXXXXXX
            President
      Physical Disability Board of Review
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