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AF | PDBR | CY2012 | PD2012 01540
Original file (PD2012 01540.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xx         BRANCH OF SERVICE: MARINE CORPS
CASE NUMBER: PD1201540   SEPARATION DATE: 20051101
BOARD DATE: 20130417


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve CPL/E-4 (0121/Personnel Clerk), medically separated for status-post (s/p) left knee posterior cruciate ligament (PCL) reconstruction. He injured his knee in 2004 during combative training and had mild to moderate symptoms of instability since that injury. Despite bracing and physical therapy (PT), the CI did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). Lower leg joint pain condition, identified in the rating chart below, was also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the left knee condition as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining condition was determined to be Category II, related to the unfitting condition diagnosis, but not separately unfitting. The CI made no appeals and was medically separated.
CI CONTENTION: “I was rated 30% disabled and unfit for duty. Therefore I should have received medical retirement with medical insurance and ID cards.”


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The VA rated the CI for back pain and this is an implied contention by the CI. The back pain was not considered by either the MEB or PEB and is therefore not within the 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 20050825
 No Original VA Exam until 20060927 – All Effective Date 20051101
Condition
 Code Rating Condition Code Rating Exam
S/P Lt Knee PCL Reconstruction 5299-5003 10% S/P Lt Knee PCL Reconstruction 5257 10% STR*/
20060927
Limited Motion & Symptomatic Pain & Instability CAT II Lt Knee Limited Motion & Pain 5260 10% STR/
20060927
↓No Additional MEB/PEB Entries↓
 Not Service-Connected x 2 No C&P
Combined: 10%
 Combined: 20%**
* CI was a no show for original C&P exams in August 2005, so the initial rating decisions were made from the STR and then a C&P exam was accomplished in 20060928 with no changes to the ratings.
** 20061012 VARD added Myofascial Back Pain at 10% raising the combined rating to 30% effective 20051101.


ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB. However, the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation.

Left Knee Condition. There were three goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.
invalid font number 31502
Left Knee ROM
(Degrees)
MEB~5Mo. Pre-Sep (20050520) Ortho ~4 Mo. Pre-Sep
(20050629)
VA C&P ~11 Mo. Post-Sep
(2006092 8 )
Flexion (140 Normal)
 “limited ROM” 105 80
Extension (0 Normal)
 0 0
Comment
 Negative Drawer and McMurray’s signs. Symptomatic pain and instability +Lachmans 1A; mildly antalgic gait; neg varus/valgus stress Painful motion
§4.71a Rating
 0% 10% 10%

The CI first injured his left knee on 24 June 2003 while running. He reinjured it almost a year later when he fell. A bone scan and X-ray were normal except for a possible joint effusion on the X-ray. Magnetic resonance imaging (MRI), a week later on 21 April 2004, revealed a possible partial tear of the medial collateral ligament (MCL). The CI was referred to orthopedics and then to PT. On 2 June 2004, the CI reported that he fell walking down wet stairs and re-aggravated his knee. He did not respond adequately to conservative treatment. A PT clinical note dated 24 August 2004 reported that the CI had signs of knee instability consistent with PCL tear. The CI underwent arthroscopic reconstruction of the PCL of the left knee on 14 December 2004. The possible tear of the MCL noted on MRI was not observed during surgery. An orthopedic examination 4 months after surgery, 19 April 2005, noted full extension of both knees and flexion reduced 5 degrees on the left compared to the right. He still showed PCL deficiency, but it was improved from the pre-operative examination. There were numerous notes in the record documenting poor compliance with the rehabilitation program as evidenced by failure to show for PT, arriving late and leaving early with poor effort manifested. The narrative summary (NARSUM), dictated on 20 May 2005, 5 months after surgery and 5 months prior to separation, documented that the CI reported continued pain and knee instability. He was unable to perform his duties as a Marine. The examiner noted that the CI was wearing a brace for walking and could only walk approximately 25 minutes before having to stop due to pain. The ROM is documented in the chart above. The CI failed to report for his initial VA Compensation and Pension (C&P) examination on 30 August 2005. A C&P examination performed on 27 September 2006, almost 11 months following separation, documented reduced ROM as noted above. The examination of the knee revealed diffuse tenderness and a small effusion. There was mild instability on the varus stress test, but none on the valgus stress test (tests for lateral instability of the knee). There was a negative Lachman’s and negative anterior and posterior drawer signs, consistent with an intact PCL. The examination of the CI’s spine, performed by the same examiner on the previous day, reported motor strength as 5/5 in both lower extremities and 2+ distal tendon reflexes in both knees. There was normal sensation in both legs. The Board noted that at a 15 July 2011 C&P examination, the CI noted stiffness, but no locking or giving way. He was unable to stand longer than ten minutes without pain. On examination, his gait was normal without swelling of either knee. The ROM was 0-130 degrees of each leg. Repetitive motion was painful, but there was no additional limitation in motion. There was no instability of the knee nor were there signs of meniscal irritation. The left knee showed mild peri-patellar tenderness. On X-ray, post-operative changes were noted with new bone formation off of the medial femoral condyle.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB coded the left knee condition analogously as 5099-5003, degenerative arthritis, and assigned a 10% rating IAW the VASRD. The PEB adjudged the limited motion, symptomatic pain, and instability to be a Category II condition, one which contributed to the unfitting condition. The VA coded the left knee condition 5257, other impairment of the knee (subluxation or lateral instability) with a 10% rating and separately coded and rated limitation of motion and pain using code 5260, limitation of flexion at 10%. The Board is charged with determination of the level of permanent disability evident at the time of separation. The NARSUM was dictated while the CI was still within the rehabilitative process; further, the compliance of the CI with therapy was documented as poor. The two C&P examinations documented ligamentous stability of the PCL and continued improvement in the examination. The mild varus instability noted on the C&P performed on 27 September 2006 was not noted on the MEB examination or on the second C&P examination, remote from separation. The Board reviewed the VASRD codes for the knee and agreed that ROM examinations were non compensable using the limitation of motion codes for the knee (5260, 5261). The Board agreed that there was evidence of left knee instability and that coding the left knee condition 5257 was supported by the first VA examination, but not the other examinations; regardless, the use of this code would provide no benefit to the CI beyond the 10% adjudicated by the PEB using the 5003 coding option. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left knee condition.
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 did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the left 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 that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
S/P Lt Knee Posterior Cruciate Ligament Reconstruction 5299-5003 10%
RATING
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120824, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         xx
         Director of Operations
         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 12 Jun 13

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:
- x former USMC
- x former USN
- x former USMC
- x former USMC
- x former USMC
- x former USMC
- x former USMC
- x former USN



                                                      xx
                                            Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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