RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00563
BRANCH OF SERVICE:  Army	BOARD DATE:  20141114
SEPARATION DATE:  20041031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (15J10/Aircraft Armament/Electronic/ Avionic Systems) medically separated for a chronic low back pain and chronic left knee pain.  The conditions 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 back and left knee conditions, characterized as “chronic low back pain with a history of bulging lumbar discs” and “left knee pain, status-post arthroscopic lateral meniscal debridement”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain” and “chronic left knee pain” as unfitting rated at 10% and 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and cited application of the US Army Physical Disability Agency (USAPDA) pain policy for the knee condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “See attached VA Form 21-4138”.  The attached contention (which included both PEB conditions as well as PTSD and headaches contentions) was reviewed and considered by the Board.

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting back and left knee condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:  

Service IPEB – Dated 20040621	VA - (7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	Chronic Low Back Strain	5237	10%	20050706	
Left knee Pain	5099-5003	0%	Residuals L/Knee Lateral Meniscus Repair, Chondromalacia Patella	5259-5014	10%	20050706	
Other x 0 (In Scope)	Other x 1		
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20050811 (most proximate to date of separation)

ANALYSIS SUMMARY:   

Low Back Pain Condition.  The CI initially complained of low back pain following an injury in 2001.  His back was further injury in a motor vehicle accident in 2002.  Diagnostic images documented bulging discs in the lower back (L3, L4 and L5 levels).  Conservative therapy such as an epidural steroid injections (into the back) and a TENS unit, did not resolve the CI’s symptoms.

The MEB examination (7 months prior to separation), reported a normal spinal exam.  The NARSUM examination (5 months prior to separation), reported “forward flexion to 110 degrees” (normal 90 degrees) and combined range-of-motion (ROM) of 240 degrees (normal 240 degrees).  The spine was minimally tender at the lumbosacral region although sensation and strength of the lower extremities were normal.

At the VA Compensation and Pension (C&P) examination (performed 8 months post separation), the CI complained of both sharp and dull pain associated with repetitive bending, stooping, or lifting.  On examination he had forward flexion to 70 degrees (normal 90 degrees) and combined ROM of 220 degrees (normal 220 degrees).  He had mild lumbar paraspinal muscle spasm with pain to palpation over the lower spine.  His gait, sensation and strength in the lower extremities were all intact.  Additional walking and repetitive lifting did not result in any increase in spasticity, fatigability or loss of ROM.  Spinal contour and gait were not mentioned.  Lower spinal X-ray images were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10% with code 5299-5237 citing localized tenderness.  The VA rated the condition at 10% with code 5237 based on decreased ROM, characteristic pain on motion testing, and muscle spasm.  ROM evidence in both evaluations supports no greater than a 10% disability rating under the General Rating Formula for Diseases and Injuries of the Spine in §4.71.  There is no pathway to any higher rating under this code as muscle spasm or guarding severe enough to cause abnormal gait or spinal contour are not present.  There were no periods of physician prescribed bed rest for any higher rating under code 5243 (intervertebral disc syndrome) for incapacitating episodes.  There was no associated radiculopathy for separate peripheral nerve 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 chronic back pain condition.

Left Knee Condition.  Review of the STR indicated that the CI had the onset of knee pain after a motor vehicle accident in September 2002 (slightly more than 2 years prior to separation).  A magnetic resonance imaging (MRI) showed a torn cartilage in the knee (the lateral meniscus).  He improved with conservative therapy and was able to deploy to Iraq, but reinjured the knee while running, 17 months prior to separation, at which time he reported that the knee was “giving way”.  He was thought to have a (lateral collateral) ligament tear by examination and instability of the knee and had to redeploy.  Surgery was performed 13 months prior to separation, showed a cartilage tear (lateral meniscus), which was debrided.  An addendum to the MEB obtained 2 months prior to separation, the CI reported that he had fallen in the shower 2 weeks after his surgery and since that time his knee gave out.  He wore a patellar stabilizing knee brace, which decreased his symptoms of giving-way.  The CI had persistent pain despite further PT and joint injections and an MEB was initiated.  

The MEB exam (7 months prior to separation), showed joint line tenderness with no evidence of instability (negative anterior and drawer signs) and no mention of ROMs or painful motion.  The NARSUM exam (5 months prior to separation) showed “full range of motion of  negative 5 to 135 degrees,” joint line tenderness over the medial joint line region, normal patellar (knee cap) mobility, no evidence of instability (of the ligaments of the knee) and mention of painful motion.  In the addendum to MEB (2 months prior to separation), the exam showed genu valgum (knock knees), some pain with pressure on the kneecap (patellofemoral compression), a positive patellar apprehension test and greater lateral excursion of the left kneecap (patella) when compared to the right.  Active and passive ROM was both 0 degrees to 115 degrees (normal, 0 degrees to 140 degrees).  X-ray images of the knee were normal.  

At the VA C&P exam (performed 8 months post separation), the CI reported that there were no active orthopedic follow-up care for his left knee condition.  The CI complained of dull constant pain in the left joint line and pain behind the patella.  The CI’s pain was worse with squatting, kneeling and climbing ladders also he complained of had intermittent swelling that increase with activities.  He did not describe any instability or “giving out”.  The CI did not give a history of using a brace and the examiner did not report one.  Exam showed intact ligaments and no instability (although the patella was not mentioned specifically), positive tenderness of the joint line space, mild patellofemoral crepitus and tenderness of the patella (positive patella grind).  The ROM was 0 degrees to 135 degrees (normal, 0 degrees to 140 degrees) without mention of painful ROM.  The CI had normal “heel-to-gait mechanics”.  X-ray images revealed good preservation in the medial and lateral joint line space, as well as patellofemoral joint on the lateral projection; there was no acute fracture or dislocation.  A diagnosis of chondromalacia patella was made and adjudged as service connected.  VA records indicated that the CI underwent left knee surgery 4 years post separation, the left knee was temporary awarded a 100% rating but did return to their original 10% rating.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition at 0% using code 5099-5003 (analogous to arthritis), with cited application of the USAPDA Pain Policy.  The VA rated the knee at 10% using code 5259-5014 (meniscal and osteomalacia) with a diagnosis of “residuals of left knee lateral meniscus repair, chondromalacia patella”.

There was no clear objective documentation of painful motion IAW VASRD §4.59 (painful motion) and ROM limitations were not to the compensable limits under specific knee flexion or extension codes.  The CI had consistent symptoms of knee pain and episodic swelling following meniscal surgery with indications of functional loss IAW VASRD §4.40 (functional loss) and pathology of the joints (crepitus and patellar instability) IAW VASRD §4.45 (the joints).  The Board considered coding analogous to 5259 (cartilage, semilunar, removal of, symptomatic) at 10% was clearly supported and considered if a higher rating using code 5259 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain and effusion into the joint); or 5257 (knee impairment/instability); or 5262 (tibia and fibula, impairment) at the “moderate” disability level was supported.  The Board adjudged that there was insufficient evidence of frequent locking or give way episodes and joint effusions, to support the higher rating under 5258 and the overall disability picture did not more nearly approximated the “moderate” level for a higher rating under 5262.  Pain (including pain with motion) is included under the 5259 coding and there was insufficient evidence for dual rating of the knee.

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 knee condition, analogous to code 5014-5259.

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 knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the low back 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 5014-5259 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 his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5299-5237	10%	
Chronic Pain Left Knee	5014-5259	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140121, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
	           XXXXXXXXXXXXXXX
	           President
	           Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150007057 (PD201400563)

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:

Encl		     XXXXXXXXXXXXXXXXXX
		     Deputy Assistant Secretary of the Army
		         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA