RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00363
BRANCH OF SERVICE:  Army	BOARD DATE:  20150515
SEPARATION DATE:  20050315

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-6 (Human Resources Specialist) medically separated for dyspnea (labored or difficult breathing), low back pain (LBP) and left knee pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “asthma, moderate persistent,” “back pain, moderate” and “left knee pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “subjective dyspnea bouts since 1998 without definitive criteria for asthma,” “non-radiating chronic LBP” and “chronic left knee pain” as unfitting, rated 0%, 0% and 0% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI’s 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 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 20041202	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Subjective Dyspnea…	6699-6600	0%	Asthma	6602	10%	20050616	
Non Radiating Low Back Pain…	5299-5237	0%	Lumbar Spine Strain	5242	10%	20050616	
Chronic Left Knee Pain	5003	0%	Residuals of Arthroscopic (sic) Surgery for Medial Meniscus
and Degenerative Joint Disease of the Left Knee	5260	10%	20050616	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 12	
RATING:  0%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20050815 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Subjective Dyspnea Condition.  The earliest service treatment record (STR) encounter dated 12 July 1998 was an incident report noting an emergent transport to the hospital for “breathing problems” upon wakening.  It further noted that her diagnosis was “asthma/bronchitis”; treated with medication, she was released from the emergency room.  After a 5-year period devoid of medical records, she was seen on 12 June 2003 for a profile update.  At that encounter, she noted to be “doing well, exercises regularly.”  She utilized inhalation bronchodilator therapy on an as needed basis.  Absent source documentation, a clinical encounter on 22 December 2003 noted that a pulmonary function test (PFT) was “normal”.  A repeat PFT on 27 October 2004 (5 months prior to separation), was normal prior to bronchodilator therapy.  Her chest x-ray was normal.  She underwent an MEB in November 2004.

At the MEB examination on 25 October 2004 (5 months prior to separation), the CI reported daytime wheezing and shortness of breath (SOB) at least twice per week as well as nighttime wheezing and SOB at least twice per month.  Her medication use was self-described as daily inhaled bronchodilator (Albuterol), nebulized albuterol 2-3 times per month, and inhaled steroid (Advair) twice daily.  The MEB physical examination (PE) was normal.  Her diagnosis was asthma, moderately persistent.  The examiner also noted that the diagnosis was one of clinical presentation as to “suspect” asthma is present prior to formal PFTs.

At the VA Compensation and Pension (C&P) examination on 16 June 2005 (3 months after separation), the CI reported being SOB upon walking two blocks.  She endorsed having four short-lived asthma attacks per month easily aborted with the use of Albuterol inhaler.  She remains symptom free between attacks.  The C&P included a list of her medications as follows, without noted dosages or directions for use:  Albuterol inhaler, Advair, Singular, Nasonex, Flonase and Allegra-D.  The STR included a single medication profile indicating Flonase (nasal steroid spray) and inhaled Albuterol last filled on 08 September 2004 with “no refills.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB analogously coded the respiratory condition under the primary code of 6600 (chronic bronchitis) with a 0% rating citing the absence of definitive criteria for asthma.  The VA, on the other hand coded the condition as 6602 (asthma) at 10% citing intermittent use of a bronchodilator.  Board members first considered the appropriate diagnosis in this case, having a difference in VASRD rating parameters.  The action officer opined and members agreed that the diagnosis of bronchitis was essentially a “clinical” diagnosis based mainly upon presenting physical symptoms, whereas asthma is diagnosed partially with symptom presentation and definitively with PFTs.  The MEB examiner clearly indicated that the listed diagnosis at that time (2 days prior to obtaining formal PFTs) was only a suspicion of asthma…pending PFT results.  Her subsequent PFT was overwhelmingly normal prior to the initiation of bronchodilator medication.  By objective evidence, asthma was not confirmed.  The CI’s persistent presenting symptoms, in light of normal PFTs, were much more in line with the diagnosis of chronic bronchitis as noted by the PEB rating.  The minimum VASRD rating under chronic bronchitis (10%) is strictly based upon PFT parameters whereas the minimum rating under asthma (10%) is based upon both, PFT parameters or the use of medication.  In this case, despite being on medication, the CI’s diagnosis of bronchitis and not asthma is subjected to rating only on PFT parameters.  The PFT results do not support the minimum 10% impairment level.  Therefore, 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’s 0% rating for the respiratory condition.

Low Back Pain Condition.  The STR contained a single emergency room document dated 10 February 2004 (13 months prior to separation) that noted her falling on ice and hurting her left side having “soreness” from her shoulder to her buttocks.  There were no other pre-service separation documents in evidence.

At the MEB Orthopedic addendum examination on 10 November 2004, the CI reported a history of non-traumatic LBP since 1998 while performing sit ups.  She endorsed having “daily back pain which increases and decreases throughout the day however it is worse at the end of the day.”  Due to pain, she endorsed the inability to perform more than minimum sit ups and pushups or the wearing of a ruck sack or a flack vest.  She also reported that physical therapy (PT) did not resolve her back pain.  The MEB PE revealed no abnormalities in regards to mobility, tenderness, spasm, or abnormal spinal contour about her low back.  Her diagnosis remained moderate back pain.

At the VA C&P examination, the CI reported intermittent painful low back symptoms since 1998.  Her flare-ups were described as occurring three times per week lasting 15 minutes.  Her activities of daily living were unaffected, excepting the inability to carry anything heavy.  The VA PE revealed normal, but painful lumbosacral range-of-motion (ROM) with weakness, fatigue, and lack of endurance upon repetitive movements.  There were inconsistent comments with regards to painful motion on non-repetitive ROM.  Her permanent profile included lower back pain as a diagnosis and the same (noted as “back problems”) was implicated in the commander’s letter.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB analogously coded the spinal condition under the primary code of 5237 (lumbosacral strain) with a 0% rating citing “full motion and no tenderness.”  The VA coded the condition 5242 (degenerative spinal arthritis) at 10% citing pain and slight limitation of motion.  The Board first considered examination probative value (PV) in this case and determined that both the MEB and VA exams contained high PV with each being just 3 to 4 months either side of service separation.  Board members agreed that although there was minimal objective physical findings, such findings of painful motion and or repetitive weakness was present to support 10% IAW VASRD §4.59 (painful motion) and or §4.40 (functional loss).  Board members also agreed with the PEBs primary coding choice in this case, but additionally noted that the diagnostic code of 5237 should stand alone and not be analogously portrayed.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the low back condition.

Left Knee Condition.  The CI first complained of left knee pain during the performance of exercises in 2003.  She denied any form of direct trauma to her knee.  Treated with PT, medications, and injections, her painful symptoms continued and she was permanently profiled on 13 November 2003 for chronic left knee pain.

At the NARSUM examination, the CI complained of the inability to walk greater than one mile without significant knee pain.  The PE revealed tenderness and a minimal deficit in left knee ROM of 135 degrees (normal = 140).  Plica (folds, [often painful] in the lubricating membrane of a joint) was palpable and significantly tender.

At the VA C&P examination, the CI reported a low grade constant pain about her left knee associated with weakness and stiffness.  Her activities of daily living were unaffected.  The PE revealed a slight left-sided limp.  There was limited and painful knee flexion at 110 degrees (normal = 140).  Repetitive movement did increase multiple parameters without effecting ROM.  Repeat left knee X-rays of 18 June 2005 (3 months after separation) revealed moderate degenerative joint disease (DJD).

Additional information from the case file revealed that the CI was involved in a “side-swiped” motor vehicle accident (MVA) on 16 March 2005, a day after her DOS.  Two clinical follow-up notes on 23 and 25 March 2005 (8 and 10 days after separation) noted a left knee effusion with tenderness.  It was listed that the X-ray of the left knee was “OK”.  Subsequent imaging studies performed on 29 March 2005 (14 days after separation) revealed a torn left meniscus.  On 19 April 2005, the CI underwent arthroscopic surgical repair of the meniscus.  At 2 months post-operatively, the CI had “excellent ROM of her knee without effusion.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left knee condition under 5003 (degenerative arthritis) with a 0% rating citing “normal motion and good stability.”  The VA coded the condition 5260 (limitation of flexion) at 10% citing pain and limitation of motion.  Board members first acknowledged the uniqueness of this case in regards to the timing of her MVA, DOS, and dates of examinations having a possible influence on a final rating recommendation.  Since her MVA occurred after separation (albeit by a single day) and before the VA examination, Board members agreed that the MEB exam, being absent any degree of impairment that might have been caused by the post-separation MVA, was actually the best representation of the CI’s condition while on active service.  At the MEB examination, her area of plica tenderness surrounding her left knee was precisely described as “significantly tender”; an indirect indication of painful motion.  Additionally, the action officer opined and members agreed that the finding of DJD in the left knee just 2 weeks after separation was not explicitly caused by the post-service MVA, but rather was present well before release from service and plausibly, was a long-term result of exercises performed and injury received in 2003.  Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3, the Board recommends a disability rating of 10% 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 subjective dyspnea (respiratory) condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Subjective Dyspnea 	6699-6600	0%	
Low Back Pain	5237	10%	
Left Knee Pain	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130913, 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, AR20160000441 (PD201400363)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA