RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00233
BRANCH OF SERVICE:  Army	BOARD DATE:  20150506
SEPARATION DATE:  20061214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Financial Management Technician) medically separated for chronic right lower extremity (RLE) pain in the anterior knee area and sub-patellar tendon.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic right leg pain” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (depressive disorder and gastroesophageal reflux) for PEB adjudication.  The Informal PEB adjudicated “chronic right lower extremity pain…” as unfitting, rated 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  His right leg condition continues to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20060907	VA* – ~2 Mos. Pre-Separation  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Lower Extremity Pain in the Anterior Knee Area and Sub Patellar Tendon…	5099-5003	10%	Right Knee Pain	5260	NSC	20061010	
Other x 2 (Not In Scope)	Other x 10	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070417 (most proximate to date of separation [DOS]).
ANALYSIS SUMMARY:

Chronic Right Lower Extremity Pain Condition.  The narrative summary (NARSUM) documented that the CI reported RLE pain from the calf to the ankle associated with physical training in November 2003 but without trauma history.  However, treatment records documented the CI reported his pain occurred after a fall during training.  He did not improve with conservative treatment and physical therapy and was referred to orthopedics.  When the orthopedic physician found no pathology, a referral to the pain clinic was made.  In regards to radiology assessments, the CI had a whole-body scan in October 2004 that was reported to be within the normal limits (WNL); X-rays of the right knee and leg in June 2005 were also reported to be WNL, and magnetic resonance imaging of the RLE was reported to be WNL as well.  The CI was evaluated in the pain clinic in February 2006 and was diagnosed with chronic pain of unknown origin; the physician determined that injections would likely not be of benefit.  The physician noted there was consideration of a somatization condition and referred the CI to physical medicine.  A physical medicine specialist in March 2006 reportedly offered no additional treatment option.  The CI underwent consultation with rheumatology in April 2006 and was diagnosed with possible reflex sympathetic dystrophy and the CI was referred back to the pain clinic and started on several medications.

In May 2006, the pain specialist recommended an MEB.  The 14 July 2006 MEB NARSUM documented the 2 June 2006 MEB physical examination that noted the CI used a cane and had an antalgic gait.  Examination of the RLE noted absence of signs of inflammation or swelling, and tenderness to palpation over the entire right knee.  Range-of-motion (ROM) of the knee and ankle was full, motor strength was slightly reduced (4/5) “due to pain” in the right knee.  Sensation and reflexes were normal.  The examiner referenced rheumatology and pain specialist examinations that showed normal ROM; however, rheumatology noted trophic changes in the RLE which refers to changes in the soft tissues that occur when nerve supply is interrupted; a month later, the pain specialist specifically noted the absence or trophic changes in the RLE.  There were no entries in the treatment records documenting muscle weakness, atrophy, crepitus, episodes of knee locking, limitation of motion, knee or ankle instability, or effusions.  The CI’s profile listed chronic right leg pain and assigned L3 designation.  His profile allowed upper and lower body weight training, walking, swimming, and biking at own pace and distance. The VA Compensation and Pension (C&P) examination, 2 months prior to separation, documented the CI’s report of “locking when pain occurs.”  The CI reported he had pain occurring 10 times per day, with pain intensity of 8/10.  He noted the pain had not caused incapacitation and was relieved by rest.  He noted he could function without medication but stated that his pain interfered with physical activity.  The examiner noted the CI required a cane for ambulation due to his knee problems and he walked with a limp.  Physical examination of the right knee noted absence of signs of inflammation, weakness, or effusion, and that right leg motion was limited by pain.  Flexion of the knee joint (right) recorded 45 degrees (normal is 140) with pain (examiner noted pain occurred at 45 degrees) and extension of 0 degrees.  There was no additional limitation following repetitive use.  Evidence of right knee instability was absent.  The examiner noted the right foot was cooler than the left, and there was no evidence of vascular compromise, tenderness, weakness, or swelling of the right foot.  The right ankle ROM dorsiflexion was 12 degrees (20 is normal) limited by pain, and plantar flexion of 26 (45 is normal) limited by pain.  Muscle strength was noted to be normal throughout and sensory function was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB used the analogous code 5099-5003 (degenerative arthritis) and rated the condition at 10% for pain slight and frequent.  The VA did not service-connect the right knee pain condition.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The higher rating of 20% under the 5003 code requires radiographic evidence of involvement of two or more major joints which is not supported by the evidence.  The Board noted that all ROM examinations were normal with the exception of the C&P examination that documented 45 degrees of flexion with pain occurring at 45 degrees.  The Board considered the ROM code 5260 (flexion) and noted the ROM recorded at the C&P exam is compensable at the 10% level; however, rating the condition under this code is of no additional benefit to the CI (IAW VASRD §4.14, avoidance of pyramiding).  The Board found no VASRD pathway to a higher rating.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB’s determination for the right lower extremity 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the RLE condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic RLE pain 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXX, AR20150018818 (PD201400233)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA