RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00522
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050414 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-6 (Military Police) medically separated for lumbar spine and left knee conditions which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The diagnoses “chronic non-radicular low back pain” and “chronic knee pain due to subluxing patella,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (post-traumatic stress disorder [PTSD]) for PEB adjudication.  The Informal PEB adjudicated the lumbar (specifying the absence of neurologic abnormality) and knee conditions as unfitting, rated 10% and 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy for the knee condition.  The PTSD condition was determined to be not unfitting.  The CI made no appeals and was released from active duty due to medical disability and transferred to the Retired Reserve List awaiting pay at age 60 pursuant to her request.  

CI CONTENTION:  The applicant makes no specific contention in her application.  Her 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 (including PTSD determined to be not unfitting by the PEB) may remain eligible for future consideration by the Army Board for Correction of Military 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:  

Admin Corr IPEB - Dated 20050304	VA* - (~5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain …	5237	10%	Lumbar Strain, History of Herniated Disc	5237	10%	20050921 	
Chronic Knee Pain Secondary to Subluxing Patella…	5099-5003	0%	Degenerative Joint Disease Left Knee	5010	10%	20050921	
			Subluxation Left Knee	5257	10%	20050921	
Other Conditions x 1 (Not In Scope)	Other x 29 (27 not service connected)	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20051229 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:    

Lumbar Spine Condition.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of a back injury from a fall in Iraq in January 2004.  The deployment was shortened for personal issues, but the CI’s back pain persisted and did not respond to conservative treatment.  Initial plain X-rays demonstrated only mild degenerative changes, but magnetic resonance imaging (MRI) late in the course (September 2004, 7 months prior to separation) demonstrated disc disease (L4/5 bulge with left annular tear, not reporting nerve impingement).  There are STR entries noting left lower extremity paresthesias, but none indicating the presence of weakness or other functional impairment; and, no surgical recommendation is in evidence.  There are a few STR entries which document grossly normal range-of-motion (ROM).  There is no STR documentation of significant ROM limitation, abnormal gait or spinal curvature, objective neurological deficits, or incapacitating episodes.  The NARSUM was conducted 31 September 2004 (7 months prior to separation) and documented constant back pain rated 5-6/10 without mention of radiation or neurological symptoms, and noted interference with running, marching, prolonged walking, and bending.  The NARSUM physical examination recorded left paraspinal tenderness (no comment regarding gait) and normal neurological findings for the left lower extremity.  The NARSUM measured ROM was 90 degrees flexion (normal 90) and combined ROM of 215 degrees (normal 240).  

A VA Compensation and Pension (C&P) examination was conducted 21 September 2005 (5 months after separation) and documented constant pain (no mention of radicular symptoms) rated 7/10 and impacting bending and prolonged sitting or standing.  The VA physical examination recorded a normal gait, spasm, tenderness, “no complaints of radiating pain on movement,” and normal strength and neurological findings (opining “no signs of intervertebral disc syndrome with ... nerve root involvement”).  The VA measured ROM was 85 degrees flexion and combined 220 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5237 (lumbar strain) was consistent with VASRD §4.71a criteria for the findings and ROM evidence (independently of the Army pain policy).  The VA’s 10% rating was consistent with the C&P combined ROM evidence.  There is no STR or VA evidence supporting a rating higher than 10%, and no indication of incapacitating episodes to support a higher rating under that formula.  The Board considered whether additional rating could be recommended under a peripheral nerve code for the residual left lower extremity radiculopathy, but members agreed that neither the requisite functional link to fitness nor the presence of a VASRD ratable deficit were supported by the evidence.  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 of the lumbar spine condition.

Left Knee Condition.  The CI injured her left knee in the same incident noted for the back injury; and, as with the back, the pain persisted in spite of conservative treatment.  She was diagnosed by orthopedics with retropatellar pain syndrome (RPPS).  Other than mild patellar degenerative changes, an MRI was normal (specifying intact menisci and ligaments).  There are STR entries documenting grossly normal ROM, the absence of subjective locking or instability, normal gait, and the absence of effusion, instability, or physical signs of impingement.  There are no STR entries contrary to any of these ratable features, none which document the use or dispensing of a knee brace, and no documentation of incapacitation.

The NARSUM documented persistent knee pain without elaboration of severity, although it was judged to be “moderate/intermittent” by the PEB (for pain policy rating), and noted functional limitations with stairs, running, marching, and prolonged walking.  The NARSUM physical examination recorded that the CI was wearing a knee brace, and noted patellar tenderness and crepitus; but, did not document tests for stability and impingement.  The NARSUM ROM measurements were flexion to 95 degrees (normal 140, minimum compensable 45) and “full” extension, specifying painful motion.

The post-separation VA C&P examiner documented constant symptoms with “severe pain when climbing stairs...necessary for her to wear a knee brace.”  The VA physical exam recorded a normal gait with use of a knee brace and swelling with “locking pain.”  The examiner further noted “recurrent subluxation which is slight in degree...[and]...drawer test [cruciate ligament stability]...with slight instability.”  Of note the examiner also recorded “slight instability” with McMurray’s test which evaluates for meniscal impingement rather than ligamental stability.  The VA ROM measurements were flexion 140 degrees and extension 0 degrees (normal) and specified painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating analogous to 5003 (degenerative arthritis) rested on application of the USAPDA pain policy which circumvents VASRD §4.59 (painful motion); and, both the NARSUM and C&P examiners specified painful ROM.  Members thus agreed that §4.59 were supported to achieve the minimum compensable rating of 10%.  The VA’s 10% rating under 5010 (traumatic arthritis) invoked painful motion; and, the VA’s additional 10% rating under 5257 (recurrent subluxation or lateral instability) referenced the “slight instability” documented in the C&P examination.  It is noted that, although, the NARSUM examiner did not document stability testing, there is adequate STR documentation that the joint was stable to stress.  Furthermore there was MRI confirmation of normal ligaments.  The CI’s knee brace may have provided pain relief and support for her diagnosis of RPPS, but was not clinically indicated for instability.  All members thus agreed that a recommendation for separate Service rating under code 5257 was not supported by the evidence.  There is no evidence for compensable ROM impairment, frequent effusions, or locking which would support a rating higher than 10% under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the left knee condition; proposing code 5024 (tenosynovitis) for its clinical compatibility with RPPS.

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 was operant in this case and it was adjudicated independently of that guidance by the Board.  In the matter of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5024, 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	
Chronic Low Back Pain Without Neurologic Abnormality	5237	10%	
Retropatellar Pain Syndrome, Left Knee	5024	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140120, 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 XXXXXXXXXXXXXXXXXXXXXX, AR20160002345 (PD201400522)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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