RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX		BRANCH OF SERVICE: ARMY
CASE NUMBER:  PD0900178		BOARD DATE: 20100401
SEPARATION DATE: 20070307
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SUMMARY OF CASE:  This covered individual (CI) was an active duty SGT (Vehicle Driver) medically separated from the Army in 2007 after 11 years of service.  The medical basis for the separation was a right knee condition.  He injured the knee from a fall in 1998.  It was complicated by the development of myositis ossificans (inflammatory formation of abnormal bone growth within muscle tissue) in the area of distal femur.  He suffered a gradual worsening of pain after the initial injury, but continued to perform within his Military Occupational Specialty (MOS).  The myositis ossificans was not diagnosed until 2004.  He was treated conservatively and was placed on temporary profiles.  He managed an Operation Iraqi Freedom (OIF) deployment in 2006 but was treated for the knee in theater.  On redeployment he was unable to perform the duties of a driver and was assigned outside his MOS.  He was placed on a permanent L3 profile and underwent a Medical Evaluation Board (MEB).  The MEB referred separate conditions, myositis ossificans and right knee pain, to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  A back condition, judged to be within AR 40-501 retention standards, was also forwarded for PEB adjudication.  Additional conditions supported in the Disability Evaluation System (DES) packet are discussed below, but were not forwarded for PEB adjudication on the DA Form 3947.  The knee pain and adjacent myositis ossificans were combined under the analogous 5003 code by the PEB and rated 10%.  The low back pain condition was adjudicated as not unfitting.  The CI was thus medically separated with a combined disability rating of 10%.
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CI CONTENTION:  The CI states: ‘Injury to my back & right femur is getting worst. ... I think my rating should be re-evaluated to see if disability should be increased or retirement.’  
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RATING COMPARISON:

Service PEB – Dated 20070111	VA (3 Mo. after Separation) – All Effective 20070308	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain, 
with … Myositis Ossificans	5099-5003	10%	Myositis of the Right Distal Femur	5260	10%	20070613	
Low Back Pain	Not Unfitting	Degen. Disc Lumbar Spine	5010-5242	10%	20070613	
No Additional DA 3947 Entries.	Non-PEB X 4 (All 0%) / PTSD (50%) granted 20080625.	20070613	
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions): 20%                                                                          	
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ANALYSIS SUMMARY:

Right Knee Condition.  The Board’s initial consideration was whether combining what are arguably two conditions into a single joint rating was appropriate in this case.  Since the myositis ossificans pathology was contiguous to the knee joint, however, all of the impairment was associated with the joint.  The Veterans Administration Schedule for Rating Disabilities (VASRD) contains a specific code for myositis ossificans (5023) directing a rating as degenerative arthritis.  It would not be IAW VASRD §4.71a, therefore, to apply separately rated codes to the condition.  Since the PEB rated analogously to degenerative arthritis, a change to the more accurate 5023-5003 code would not meaningfully affect its adjudication.  The PEB’s DA Form 199 referenced application of the US Army Physical Disability Agency (USAPDA) pain policy to its rating.  Since there was no compensable range of motion (ROM) impairment, however, the PEB’s 10% rating determination was concordant with the VASRD.  Goniometric ROM measurements were 125° flexion by the MEB and 130° by the VA.  There was no instability noted on either exam (or in the records) which would justify additional knee codes for rating.  The VA likewise did not apply the 5023 myositis ossificans code but defaulted to the joint code for limited flexion, invoking painful motion to achieve a 10% rating.  The PEB coding was actually more congruent with §4.71a.  The CI achieved a 20% rating for the knee on a subsequent evaluation.  This was based on an exam two years after separation with a commensurate effective date, well outside the Board’s 12 month window as specified in DoDI 6040.44.   All evidence considered there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB adjudication for the right knee/myositis ossificans condition.

Low Back Condition.  The CI reported an onset of low back pain after jumping from a humvee during his 2006 OIF deployment.  There are no records showing that he was treated in theatre but he was evaluated for the condition by the post-deployment health clinic on return and referred for chiropractic care.  A Magnetic Resonance Imaging (MRI) demonstrated mild disc disease at L3/4 without canal or nerve root involvement.  There was some occasional bilateral sciatic radiation, but no clinical radiculopathy.  Neurologic exams were normal and ROM’s were generally unremarkable.  The MEB orthopedist did not elaborate on the condition in his narrative summary (NARSUM), but provided details in the MEB physical that stated it was ‘aggravated by prolonged standing & standing, bending, running, lifting and wearing gear’.  The orthopedist entered low back pain as within AR 40-501 standards on the DA Form 3947, but his rationale is not in evidence.  There are fairly detailed outpatient notes regarding the back condition in the service treatment record.  There are no entries which document physical limitations supporting a conclusion that the condition was unfitting.  The L3 profile was only for the knee condition, although those restrictions would also provide some shelter for any back limitations.  The Commander’s statement was exclusively centered on the knee condition.  Although it is possible that the back condition would have surfaced as separately unfitting had it not been overshadowed by the knee condition, that potential is unduly speculative as a basis for a Board recommendation to that effect.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB fitness adjudication for the lumbar condition.

Other Conditions.  The MEB physical documented swelling of the nasal turbinates with intermittent difficulties breathing through the nose.  This condition was diagnosed as allergic rhinitis and rated 0% by the VA.  No acute issues complicating the nasal condition are identified in the records and no link to fitness can be drawn.  The MEB physical also identified a history of ankle sprains.  Each ankle received a non-compensable rating from the VA.  There was no complaint or treatment for either ankle evidenced during the MEB period.  Nothing would support a Board recommendation that either ankle was unfitting.  The only other condition rated by the VA at separation was hallux valgus of the right great toe.  This was not identified on the MEB physical or elsewhere in the DES packet and is therefore not eligible for Board consideration.  It is noted that the CI was subsequently service connected for PTSD by the VA (rated 50%) as a consequence of the 2006 OIF deployment.  This was based on an examination 18 months after separation with a commensurate effective date.  The VA rating decision stated, ‘Review of your service treatment records shows no treatment for or a diagnosis of posttraumatic stress disorder.’  The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES.  PTSD or any contended conditions not covered above remain eligible for Army Board for Correction of Military Records (ABMCR) consideration.  The Board, therefore, has no reasonable basis for recommending any additional unfitting conditions for separation rating.
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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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the right knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back condition, the Board unanimously recommends no recharacterization of the PEB adjudication as not unfitting.  In the matter of the nasal condition, bilateral ankle sprain conditions or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.
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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090205, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.