RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00274
BRANCH OF SERVICE:  Army	separation date: 20070316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Military Police) medically separated for a low back condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for an Medical Evaluation Board (MEB).  Lumbar spondylosis was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified latent TB infection; patellofemoral syndrome; shin splints; myopia; and hearing loss for PEB adjudication.  The Informal PEB adjudicated lumbar spondylosis with facet hypertrophy, without neurologic deficit as unfitting, rated 10%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  His right knee and leg, and back conditions continue to worsen.  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 20070226	VA* - (~1 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Spondylosis…	5242	10%	Lumbar Disk Disease	5237	10%	20070430	
Patellofemoral Syndrome	Not Unfitting	Right Knee Strain	5257	10%	20070430	
Other MEB/PEB Conditions x 4 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070525 (most proximate to date of separation [DOS)])

ANALYSIS SUMMARY:

Lumbar Spondylosis with Facet Hypertrophy without Neurologic Deficit Condition.  The earliest note in the service treatment record (STR) dated 14 June 2006 indicated the CI complained of left lower back pain for 8 months, which was intermittent and was worse with movement, but without radiation, weakness, or paresthesias (tingling or “pins and needles”).  Treatment consisted of Naproxen (a nonsteroidal anti-inflammatory drug (NSAID)) and Flexeril (Cyclobenzaprine, a muscle relaxer).  A lumbar spine X-rays series revealed no spondylolisthesis (one vertebra slides forward over the bone below it) or lumbar spine fracture.  Physical therapy was instituted, but significant progress was not made.  In July 2006 the CI noted the onset of pain was during IET (initial entry training) and was gradual over time, but became constant.  He had a normal gait and a full active range-of-motion (ROM).  There was focal tenderness of the L4 segment with hypermobility and increased muscle tension/spasm on the right paravertebral musculature.  An MRI dated 26 September 2006 demonstrated diffuse annular disc bulging at the L1-2 and L5-S1 levels and facet hypertrophy (degeneration and thickening at the vertebral joints) at L3-4 and L4-5.  Orthopedic evaluation in October 2006 resulted in a diagnosis of lumbar spondylosis (osteoarthritis of the joints between the center of the spinal vertebrae) for which Celecoxib (an NSAID) was prescribed.  In January 2007, a physical therapist noted the ROM measurements with an inclinometer were flexion 100 degrees and extension 25 degrees with painful motion.  In February 2007 physical therapy ROM measurements with an inclinometer were flexion 95 degrees and extension 20 degrees (see chart below) with limitation of motion due to pain.

A permanent L3 profile was issued in December 2006 for lumbar spondylosis of L2-L3 and L3-L4 with limitations of all military functional activities and physical fitness training and testing.  He was also limited from standing for greater than 20 minutes per hour as well as no driving or riding in tactical vehicles.  The commander’s statement dated 9 January 2007 indicated there was no decline in the CI’s performance after being diagnosed with lumbar spondylosis; however, his profile limited him to carrying on 30 pounds.  Therefore, he was unable to wear law enforcement body armor or other law enforcement gear, Kevlar, or load bearing equipment or carry an assigned weapon or ride in or drive a tactical vehicle.  The commander recommended the CI be released from active duty due to his medical condition.  During his MEB DD Form 2807-1, Report of Medical History, examination on 24 January 2007, the CI reported he had lower back pain due to lumbar spondylosis.  The MEB physical examiner noted on the DD Form 2808, Report of Medical Examination, dated 6 February 2007, a full ROM of the spine with pain at the limits of flexion and rotation, no tenderness to palpation, a normal tandem gait, normal strength, negative straight leg raises (to determine nerve root irritation) bilaterally, and slight preservation of the lordotic curve in the lumbar spine with flexion.  The MEB narrative summary (NARSUM) dated 13 February 2007 noted the CI was limited to sedentary activities and the examiner opined the CI’s “pain should decrease if no longer required to perform activities required of a soldier.”

At the VA Compensation and Pension (C&P) examination dated 30 April 2007, the CI reported the back pain radiated into his buttocks bilaterally and into his right leg.  He did occasionally use a brace and a cane.  On examination there was tenderness of the spine and the paravertebral muscles on palpation.  Forward flexion was 90 degrees with pain; extension was to 20 degrees with pain; left and right lateral rotation were to 30 degrees with pain; and left and right lateral flexion were 30 degrees with pain.   There was no loss of motion on repetition.  A straight leg raise (to determine nerve root irritation) was positive on the right and the neurologic examination was unremarkable.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	PT
~1 Mo. Pre-Sep	MEB DD Form 2808
~1Mo. Pre-Sep	VA C&P General
~1 Mo. Post-Sep	
Flexion (90 Normal)	(90)95	Full ROM	90	
Extension (30)	20		20	
R Lat Flexion (30)	10		30	
L Lat Flexion (30)	10		30	
R Rotation (30)	(30)35		30	
L Rotation (30)	30		30	
Combined (240)	190		230	
Comment	Measured with an inclinometer; motion limitation due to pain	Pain at the limits of flexion and rotation; no tenderness to palpation; tandem gait normal	Tenderness of the spine and paravertebral muscles; pain at the last 10 degrees of each ROM; straight leg raise positive on the right	
§4.71a Rating	PEB 10%	10%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5242 (Degenerative arthritis of the spine).  The VA assigned a 10% rating using code 5237 (Lumbosacral strain).  The Board sought a route to a higher rating.  However, in the absence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis, or incapacitation, the Board was unable to find a route to a higher rating.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  Functional impairment linked to fitness is required to support a recommendation for addition of a peripheral nerve rating to disability in spine conditions.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 lumbar spondylosis with facet hypertrophy condition.

Contended PEB Condition.

Patellofemoral Syndrome Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that patellofemoral syndrome condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The patellofemoral syndrome condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.

A note dated 25 May 2005 indicated the CI had increasing pain in the right knee and distal thigh.  The right thigh was tender to palpation, while both thighs had a normal appearance, no misalignment or weakness.  The knees were had a normal appearance and were not tender to palpation.  An X-ray was reported to be normal, although the impression was a stress fracture.  An X-ray series of the right tibia dated 13 September 2005 demonstrated continued remodeling of the periosteal reaction overlying the posteromedial tibial stress fracture.  Crutches were to be used at all times until the CI’s gait was non-antalgic.  A physical therapy note dated 12 October 2005 indicated knee motion was normal and there was no effusion, tenderness to palpation, laxity, meniscal signs or positive patellar grind or compression tests; the legs were also normal on examination.  On 12 October 2015 the CI had pain on motion at the end of the ROM of knee flexion with an antalgic gait on the right, but the knee was otherwise normal.  There was pain on palpation at the middle of the medial tibial shaft.  By 28 October 2005 shin pain resolved and the crutches had been discontinued 2 weeks earlier.  However, some knee pain symptoms were persisted and quadriceps strengthening continued.  A physical therapy note dated 10 November 2005 for follow-up of a right tibial stress fracture and right patellofemoral syndrome indicated knee motion was normal and there was no effusion, tenderness to palpation, laxity, meniscal signs or positive patellar grind or compression tests; the legs were also normal on examination.  The MEB NARSUM noted the history of shin splints and the patellofemoral syndrome during basic training and the extremities were checked off as normal at the MEB’s DD Form 2808 on 6 February 2007.

At the VA C&P examination in April 2007 the CI indicated he had shin splints that gave rise to his knee and back pain.  On examination there was tenderness to palpation of the right knee.  Flexion was full at 140 degrees with pain.  Extension was full at 0 degrees.  With repetition there was no change in the ROM or pain pattern and there was no instability or evidence of a meniscal tear.  The VA assigned a 10% rating using code 5257 (Recurrent subluxation or lateral instability), but the Board was unable to find any evidence in the VA examination, VA Rating Decision (VARD), or in several pre-separation examinations including the MEB examination to support that finding or rating.

The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that the patellofemoral syndrome condition significantly interfered with satisfactory duty performance.  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 patellofemoral syndrome contended condition and so no additional disability rating is recommended.

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 lumbar spondylosis with facet hypertrophy without neurologic deficit condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended patellofemoral syndrome condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20131231, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160000431 (PD201400274)

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