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AF | PDBR | CY2012 | PD 2012 01635

Original file (PD 2012 01635.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX CASE : PD -20 12 - 0 1635
BRANCH OF SERVICE: MARINE CORPS BOARD DATE: 201 4 0325

Separation Date: 20020726

SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve LCPL/E-3 (0627/Satellite Communications Operator) medically separated for bilateral knee conditions. He began experiencing pain in his left knee in 2001 from surgery that took place pr ior to entering the military. The left knee pain resolved , but he injured his right knee running while on “ boot leave ” (before he began entry level training). H e declined recommended surgery for his right knee . Despite physical therapy (PT) treatment , his knees could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards and was referred for a Medical Evaluation Board (MEB) . The MEB forward ed the diagnoses of “right knee partial anterior cruciate ligament ( ACL ) tear,” “left knee status post (s/p) ACL reconstruction” and “bilateral patellar lateral facet compression syndrome” to the Physical Evaluation Board (PEB ) IAW SECNAVINST 1850.4E. The PEB adjudicated “bilateral patellar lateral facet compression syndrome” as Category I (unfitting conditions) , unfit and rated 10%. The left knee s/p ACL reconstruction and right knee partial ACL tear wer e determined to be Category III ( not separately unfitting and not contributi ng to the unfitting condition ) . The CI made no appeals and was medically separa ted .

CI CONTENTION : “I XXXXXXX have been through 4 knee surgeries. I lost almost 3 years of employment. I also can’t bend or walk up stairs because of this condition. Walk with perment [sic] limp and constent [sic] pain, lack of flexability, instability, soarness, stiffness & numbness. I work in the construction field and this disability has keep me from moving up and getting raises because of my lack of mobility. I am incapabill [sic] of working way I use to before my service connected disability. I have 2 small children and I fear that I will not be able to compete and excell because of this injury.” [ sic ]

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 all knee conditions are 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.

RATING COMPARISON :

Service IPEB – Dated 20020715	VA - based on Service Treatment Records (STR)*
Condition	Code	Rating	Condition	Code	Rating	Exam
Bilateral Patellar Lateral Facet Compression Syndrome	5299-5003	10%	Right Knee Condition (Patellofemoral Syndrome)	5257	0%	STR
Left Knee Status Post ACL Reconstruction	Not Unfitting (Cat III)	No VA Entry
Right Knee Partial ACL Tear	Not Unfitting (Cat III)
No Additional MEB/PEB Entries	Other x 0
Combined: 10%	Combined: 0%

Derived from VA Rating Decision (V ARD) dated 20031103.

ANALYSIS SUMMARY : The Board notes the presence of a diagnosis, in and of itself, is not sufficient to render a condition unfitting and ratable. While the Disability Evaluation System considers all the member's medical conditions, compensation can only be designated for those medical conditions that cut short a member's career, and then only to the degree of severity present at the time of final disposition. The Department of Veterans Affairs, operating under a different set of laws (Title 38, United States Code), is empowered to periodically re-evaluate veterans for the purpose of adjusting the disability rating should the degree of impairment vary over time.

The PEB rated the b ilateral k nee p ain condition under the single analogous code 5 2 99-5003 a rthritis, degenerative (hypertrophic or osteoarthritis) ; the Board , though, must recommend ratings in accordance with VA Schedule for Rating Disabilities ( VASRD ) guidance . IAW VASRD §4.7 (h igher of two evaluations), the Board must consider separate ratings for PEB bilateral joint adjudications , but must also satisfy the requirement that each “unbundled” condition was reasonably justifie d as unfitting in and of itself ( with the caveat that the final recommendation may not produce a lower combined rating than that of the PEB ) .

Bilateral Patellar Lateral Facet Compression Syndrome Condition . The CI underwent a left knee ACL reconstruction with allograft in Janu a ry 1999 , prior to entry into military service . H e reported some pain after the surgery and also suffered an injury to the left knee , while in service, 15 months prior to separation. He complained of left knee pain for 2 days and was diagnosed with a mild strain , but no further treatment notes concerning the left k nee were present for review. Thirteen days after the left k nee injury t he CI sustained a twisting injury to his right knee while running . He presented for care and the treatment note documented full range - of - motion ( ROM ), minimal effusion and mild local tenderness over the anterior , lateral aspect of the knee . The plain film X -ray was normal and the examiner diagnosed a right knee sprain . Two days later, an evaluation by an orthopedist noted subjective “giving out , ” limited right knee ROM with pain and no physical exam signs of instability. The examiner’s impression was questionable ligament tear and he ordered a knee immobilizer and further testing. A m agnetic r esonance i magining (MRI) study that day demonstrated a parti al ACL tear with bone bruises, moderate supra-patellar joint effusion and a popliteal cyst. The CI was placed on l ight d uty from 7 to 15 June 2001 for right knee strain . His right knee pain persisted and he was referred to PT for treatment/rehabilitation of the partial right ACL tear. He was treated by PT for 8 weeks but was not able to return to full duty. A repeat MRI of the right knee 6 months prior to separation revealed resolution of the bone bruises, near complete resolution of the joint effusion and no full-thickness tear of the ACL was seen. Comparison with the prior MRI performed in April 2001 raised the possibility of a partial chronic tear. PT was continued for 2 more weeks, but when the CI did not further respond to therapy a diagnostic arthroscopic surgery was recommended. The MEB n arrative s ummary (NARSUM) exam ( 3 months prior to separation ) repor ted that both a civilian and VA o rthopedist had recommended right knee surgery ( the VA o rthopedist felt that there was no instability on exam), but the CI declined all surgical options. The CI had pain in both knees, with the right knee worse than the left . The NARSUM examiner indicated that the CI should not participate in any deployable duties, no impact activities, no running , no prolonged standing, sitting, squatting or bending. The physical exam findings revealed that both knee s were essentially the same, with ROM of 0 degrees -130 degrees (0 degrees – 140 degrees being normal), no sign of instability or meniscal injury and both knees had tenderness of the patella at the lateral facets. The MEB physical exam , documented on DD Form 2808 ( less than 2 months prior to separation ), document ed right knee ROM of 120 degrees with painful motion and tenderness of the right medial patella during the compression test. There was no documentation concerning the left knee. The commander’s n on- m edical a ssessment (NMA) noted that the CI could not participate in any drills or perform his MOS duties ( presumably due to the right knee injury , though not specified) . T he VA Compensation and Pension exam , completed a lmost 17 months after separation , documented another right knee injury for which he was scheduled to undergo arthroscopic surgery in December 2003. He complained of worsening left knee pain with reported “ weakness, stiffness, occasional swelling, instability, g iving way, and locking in the am, fatigability in the pm and lack of endurance ” in that joint . The CI was wor king as a masonry worker at the time. The examiner noted t he CI was able to walk without an assistive device, had an antalgic gait and was able to perform de ep knee bends. Physical exam ination re ported no swelling or effusion of the right knee. The right knee ROM was 0 degrees – 140 degrees with painful motion and mild to moderate tenderness at the lateral joint line. There was evidence of mild ligamentous laxity witho ut gross instability and mild weakness of the right quadriceps with n ormal hamstring strength. L eft knee exam ination revealed no gross joint swelling or effusion with no joint line tenderness. The active ROM was 0 degrees to 140 degrees without pain. There were some positive and negative findings related to instability of the left knee. Muscle strength of the quadriceps and hamstrings was normal and there was no neurological deficit in the left lower extremity.

The Board direct s attention to its rating recommendation based on the above evidence. The PEB applied the analogous VASRD code 5 2 99-5003 ( degenerative arthritis ) , to the bilateral patella lateral facet compression syndrome and rated it 10%. The VA applied code 5257, other impairment of the knee, to the “ right knee condition/patellofemoral syndrome ” and rated it 0% based on the STR. The Board considered the PEB’s adjudication of the CI’s bilateral kn e e condition under a single VASRD code in deliberating its rating recommendation. The record was silent for 14 months prior to separation for any issue s concerning the left knee. The CI did have some left knee pain from a pre-service surgical procedure , but there is no evidence that it limited his duty in anyway. The left knee was never noted on any limited duty report nor was it implicated by the NMA. T h ough there was evidence of post- separation worsening, the VA never granted a disability evaluation for the left knee. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. All documentation related to the left knee condition was reviewed by the a ction o fficer and considered by the Board. After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the any of the left knee conditions , so no additional disability ratings can be recommended.

The Board next considered the CI’s right knee condition for its rating recommendation. Board members agree that the evidence supports the CI’s right knee condition as separately unfitting , so this would support a separate rating recommen dation. All evidence, though, indicate s the right knee had non-compensable ROM measurements, no meniscal pathology and no instability ( as required for app lication of knee- specific VASRD codes ) . Application of VASRD §4.59 (painful motion) and §4.40 (functional loss) is appropriate based on the evidence ; using code 5003 this would indicate a 10% rating, which was the same percentage of disability adjudicated by the PEB. The disability related to the right knee ACL partial tear condition (adjudicated as Category III by the PEB) is captured in the 10% rating under 5003 IAW VASRD §4.14 (avoidance of pyramiding; evaluation of the same disability under various diagnoses is to be avoided). The Board concluded that no appropri ate VASRD coding option would result in a rat ing higher than 10% . C hang ing VASRD coding with out changing percent disability confers no 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 b ilateral p atellar l ateral f acet c ompression s yndrome.

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 . As discussed above, the PEB ’s disability rating was based on a bilateral joint condition while the Board’s recommendation was considered independently of that adjudication. In the matter of the b ilateral p atellar l ateral f acet c ompression s yndrome 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 recommends n o re - characterization of the disability and separation determination .

invalid font number 31502

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20 120901 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
President

Physical Disability Board of Review

invalid font number 31502

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 15 Dec 14

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

- XXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXX, former USMC

XXXXXXXXXXXXXX
Assistant General Counsel

(Manpower & Reserve Affairs)

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AF | PDBR | CY2012 | PD 2012 01635

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