RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00690
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041026

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve, E6, Transportation Management Coordinator,  medically separated for “chronic low back pain” and “chronic pain, left knee,” rated at 10% and 10%, respectively, with a combined disability rating of 20%.   

CI CONTENTION:  The applicant makes no specific contention in her application.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 Physical Evaluation Board (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 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:  

SERVICE PEB - 20040514	VARD - 20060630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Chronic Low Back Pain	5237	Deferred	20050512	
			Thoracic Disability	5299-5237	Deferred		
Chronic Pain, Left Knee	5099-5003	10%	Synovitis/Patellofemoral Pain Syndrome, Left Knee	5024	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed low back pain (LBP) while in the Reserves, prior to being activated, and was placed on a P2 profile and anti-inflammatory medications.  After activation, she reported worsened LBP.  She had an orthopedic evaluation and magnetic resonance imaging (MRI) of the lumbar spine on 10 December 2003 was normal.  At an orthopedic follow-up visit on 26 January 2004, the CI reported LBP that radiated to the right buttocks area, and occasionally to the left.  The back exam was normal, with no muscle spasm noted.  No surgery was recommended and despite treatment with profiles, therapy, and medications the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of her military specialty and an MEB was initiated.  

At the MEB NARSUM examination performed 5 February 2004, the CI reported LBP.  The MEB physical exam noted tenderness to palpation (TTP) in the right lumbar area.  The thoracolumbar (TL) range-of-motion (ROM) was normal as noted in the ROM chart above.  There was normal strength, sensation, and reflexes of both lower extremities (LEs) and straight leg raise testing was negative.  The CI was able to walk on heels and toes without difficulty.  At a pain management visit on 21 September 2004, the CI reported her back pain was somewhat improved since therapy and decreased levels of activity and full ROM was noted on exam.  

At the VA Compensation and Pension (C&P) examination on 12 May 2005, 7 months after separation, the CI reported frequent pain and stiffness of the low back with radiation to the right buttock.  The examination noted TL ROM as noted in the ROM chart above.  There was no additional loss of ROM with repetition and SLR was negative.  There were no significant abnormalities noted on X-rays of the thoracic spine on 9 February 2005.  A normal anatomical variation of a transitional vertebral element was noted on the lumbosacral X-rays without evidence of degenerative disc disease or spine fracture.  Additional thoracic X-rays were ordered to evaluate for scoliosis.

A second VA C&P Spine examination was performed on 15 July 2006.  The CI reported mid-thoracic and waistline pain radiating to the right buttock.  The examination of the TL spine was completely normal with painless, full ROM noted as noted in the chart above, and examination of the bilateral LEs was normal.  The thoracic spine X-rays dated 12 May 2005, ordered following the initial C&P examination, were normal without scoliosis noted.  The VA examiner indicated there were no abnormalities noted on examination or imaging and evaluation of the thoracic and lumbar spine was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5299-5237 (analogous to lumbosacral strain).  The original VA rating decision dated 30 June 2006 deferred the rating decision pending review of a scheduled VA Spine examination, following which the 9 May 2007 VARD denied service-connection on the basis that there was no evidence of chronic disability due to the low back condition at the C&P exam performed on 15 July 2006.  The Board agreed that the evidence in record supports a 10% rating according to the VASRD General Rating Formula for Diseases and Injuries of the Spine in effect on the date of separation based upon the presence of lumbar tenderness on the MEB NARSUM examination and full, but painful ROM noted at the initial VA C&P examination.  The Board reviewed to see if the next higher rating was supported but there was no limitation of TL motion to support a minimum rating and there was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour.  The Board next reviewed to see if a higher evaluation than 10% was achieved coding with 5243 (Intervertebral disc syndrome) and alternatively rating based on incapacitating episodes, defined by the VASRD as bed rest prescribed by a physician and treatment by a physician.  However, there was no documentation in record of incapacitating episodes as defined.  Finally, there was no evidence of peripheral nerve impairment related to the back condition to support additional 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 low back condition.  

Chronic Pain, Left Knee.  According to STRs and the MEB NARSUM, the CI also developed left knee pain while in the Reserves, along with LBP as noted above, and was placed on a P2 profile.  After activation, she reported worsened left knee pain.  The CI had an orthopedic evaluation and left knee X-rays were normal and MRI 10 December 2003 showed inflammation of the joint lining (synovitis) and of a bursa behind the knee (bursitis), without evidence of bone, ligament, or meniscal (semilunar cartilage) damage.  In January 2004 the orthopedic assessment was nonsurgical left knee pain.  Despite treatment with profiles, therapy, medications, and knee injection, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of her military specialty and an MEB was initiated.

The CI was subsequently referred for a second orthopedic consultation after a change of station and the evaluation 16 April 2004 noted a three year history of intermittent knee pain.  The examination showed a normal gait.  There was TTP of the patella and a positive patellar compression test, without effusion.  The knee was stable and there was no evidence of meniscal injury.  Knee ROM was 130 degrees flexion (normal 140) and lack of 5 degrees of extension (minus 5 degrees, normal 0 degrees).  Lateralization of the patella (patella offset to the outside of the knee from its normal anatomical position) was noted on X-rays.  The orthopedic diagnosis was retropatellar pain syndrome and a medial plica syndrome (abundant, inflamed soft tissue of the joint).  Continued therapy was recommended for approximately 6 months before consideration of arthroscopic surgery to excise the plica and the MEB was continued.

At the MEB examination the CI reported left knee pain.  The MEB physical examination noted no swelling.  Knee ROM was as noted in the ROM chart above.  

At the VA Compensation and Pension (C&P) examination on 12 May 2005, 7 months after separation, the CI reported she could walk for 1-3 miles and work on her feet for an 8-hour shift, with sitting breaks every 90 minutes.  On examination there was no crepitus, patellar grinding, or instability and no patellar or meniscal abnormalities were noted.  Knee ROM was as noted in the ROM chart above.  There was painful motion and no additional loss of ROM with repetition.  Knee X-rays on 9 February 2005 were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis), and cited the USAPDA pain policy.  The CI appealed to the Formal PEB (FPEB) and later to the USAPDA, both offices affirmed the PEB findings and ratings.  The VA rated it 10%, coded 5024 (tenosynovitis) and cited painful, limited motion of a major joint.  The Board agreed that the evidence supports a 10% rating for the knee condition coded according to 5003 rating criteria (as is 5024) or coded as 5299-5260 (analogous to limited leg flexion) for painful motion IAW VASRD 4.59 (Painful motion).  The Board reviewed to see if a higher rating was supported with any applicable code.  However, the examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), frequent locking with effusions or any indication of dislocated meniscus or loose body (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  The Board noted that the PEB reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating.  In this case, a 10% rating is also supported according to 5003 rating criteria as noted above and, therefore, no change to the PEB coding choice is recommended.  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 knee condition.  

BOARD FINDINGS:  In the matter of the low back and knee conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  There were no other conditions within the Board’s scope of review for consideration.  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 20140206, 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 XXXXXXXXXXXXXXXXXX, AR20160005586 (PD201400690)

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