RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00730
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E8, Food Service Operator, medically separated for “neck, low back, left ankle, and right knee pain conditions,” rated 10%,10%,0% and 0% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI was not evaluated for his PTSD condition which the Department of Veterans Affairs (VA) has rated at 70%. The CI’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 Physical Evaluation Board (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 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 - 20070103	VARD - 20071011	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5237	10%	Degenerative Disc Disease, C-Spine	5242	20%	20070717	
Chronic LBP	5299-5237	10%	Degenerative Disc Disease, L-Spine	5242	20%	20070717	
Left Ankle Instability	5099-5003	0%	Status Post Left Ankle Injury	5271-5003	10%	20070717	
Right Knee Pain w/Injury	5099-5003	0%	Chondromalacia, Rt Knee	NSC	20070717	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Neck Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the neck condition began approximately 2 years prior to referral for MEB.  The CI was struck in the face by a duffle bag snapping his head back.  An X-ray showed spine straightening, degenerative disc disease (DDD), and generalized osteophytosis (presence of osteophytes [bone spurs]).  An MRI showed minimal disc bulging and anterior osteophytic changes in C6-7.  An X-ray showed spine straightening compatible with muscle spasm and unchanged osteophytosis and DDD.  The NARSUM, 8 months before separation, recounted the history and interventions.  The CI complained of bilateral neck pain since the inciting hyperextension injury, which had improved over time.  There was no associated arm pain, imbalance, or fine motor problems.  He experienced no significant relief from conservative management.  The examiner referred to the physical therapy (PT) range-of-motion (ROM) measurements.  The physical examination documented a normal gait.  The cervical spine examination revealed paravertebral muscle tenderness.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings from the X-rays and MRI.  The diagnosis listed cervical spine DDD at C6-C7.  The surgeon opined that surgical treatment was not indicated.  Pain limited ROM, measured by PT with a goniometer, documented flexion was 40 (45 normal), extension was 35 (45), bilateral lateral flexion was 35 (45), right rotation was 55 (80), and left rotation was 50 (80) degrees.  Repetitive ROM, measured by PT with a goniometer, documented flexion was 40/40/40 (45), extension was 40/40/40 (45), bilateral lateral flexion was 35/35/35 (45), right rotation was 45/45/45 (80), and left rotation was 50/50/50 (80) degrees.  The physical examination revealed paravertebral muscle tenderness and pain and mechanical limitation with ROM.  The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of chronic neck pain, stiffness, and decreased motion, since injury.  Pain was characterized as mild, dull, and burning.  The CI denied flare-ups, radiation, numbness, paresthesia (abnormal sensation, tingling, burning, prickling), weakness, spasms, or fatigue.  The active medication was an opioid receptor agonist (Tramadol).  The physical examination documented a normal gait, spine symmetry, and no abnormal spinal curvature.  The cervical spine examination revealed tenderness and pain with motion but no spasm, atrophy, guarding, or weakness.  There was no muscle spasm, localized tenderness, or guarding severe enough to cause an abnormal gait or spinal contour.  Active ROM values were flexion of 30 (45), extension of 25 (45), right lateral flexion of 35 (45), left lateral flexion of 40 (45), and bilateral rotation of 50 (80) degrees.  There was no additional loss of motion on repetitive use.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the X-rays and MRI.  The diagnosis listed chronic neck pain due to mild DDD and osteophyte at C6-C7.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral or cervical strain), citing chronic neck pain since injury while deployed, C6-C7 DDD, paravertebral muscles tenderness, normal strength, pain with ROM,  condition existed prior to service, but was compensable under 10USC 1207A.  The VA assigned a 20% rating under the 5242 code (degenerative arthritis of the spine) based on the VA C&P examination 5 months after separation, citing neck injury, disc bulging by MRI, degenerative changes at C6-7, DDD, ROM, and  painful motion.  The ROM values in the PT examinations were consistent with the 10% rating and the C&P examination ROM values were consistent with the 20% rating.  Recognizing the temporal relationship to the date of separation, the board considered the relative probative value of the proximate exams (PT and C&P).  The Board assigned more probative value to the PT exams because they documented comprehensive and repetitive cervical spine ROM measurements with a goniometer.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  While the proximate examinations documented tenderness, there was no evidence of muscle spasm, abnormal spinal contour, or abnormal gait.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  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 neck condition.

Low Back Condition.  According to the STR and NARSUM, the back condition began approximately 7 years prior to referral for MEB.  The CI injured his back while wrestling an inmate at his regular corrections job.  Serial X-rays showed spine straightening, anterior osteophytosis, and DDD.  An MRI showed mild DDD with a minute L4-L5 disc tear and a possible L2-L3 disc tear.  In the NARSUM, the CI complained that his back had worsened since the initial injury, and during his deployment.  He reported associated left leg radicular symptoms but denied tingling, groin numbness, saddle numbness, balance problems, or fine motor problems. The examiner referred to the PT documents for lumbar spine ROM.  The physical examination documented a normal gait and the focused examination revealed lower lumbar spine tenderness.  The straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root radiculopathy) were negative.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings from the X-rays.  The diagnosis listed lumbar spine aggravation of spondylosis (spine degenerative disease) with mild radiculopathy.  The surgeon opined that surgical treatment was not indicated.  Pain limited ROM, measured by PT with a goniometer, documented flexion was 70 (90), extension was 35 (30), right lateral flexion was 20 (30), left lateral flexion was 25 (30), right rotation was 30 (30), and left rotation was 25 (30) degrees.  Repetitive ROM, measured by PT with a goniometer, documented flexion was 65/65/65 (90), extension was 10/10/10 (30), right lateral flexion was 20/20/20 (30), left lateral flexion was 25/25/25 (30), right rotation was 25/25/25 (30), and left rotation was 20/20/20 (30) degrees.  There was pain and mechanical limitation to the ROM.  The physical examination documented “no antalgic gait.”  The spine examination revealed decreased lumbar curve and tight and tender paravertebral muscles.  In the C&P exam, the CI complained of progressive low back pain, stiffness, and decreased motion, since injury.  Pain was characterized as mild, dull, and burning.  The CI denied flare-ups, radiation, numbness, paresthesia, urinary retention, incontinence, erectile dysfunction, weakness, spasms, falls, unsteadiness, or fatigue.  The physical examination documented a normal gait, normal posture, spine symmetry, and no abnormal spinal curvature.  The lumbar spine examination revealed tenderness and pain with motion but no spasm, atrophy, guarding, or weakness.  There was no muscle spasm, localized tenderness, or guarding severe enough to cause an abnormal gait or spinal contour.  Strength, sensation, and DTRs were normal.  Active ROM values were flexion of 60 (90), extension of 20 (30), right lateral flexion of 25 (30), left lateral flexion of 30 (30), right rotation of 30 (30) and right rotation of 25 (30) degrees.  There was no additional loss of motion on repetitive use.  The examiner recounted the findings of the X-rays and MRI.  The diagnosis listed chronic low back pain due to mild DDD and osteophyte at L4-L5.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral or cervical strain), citing chronic low back pain, injury prior to mobilization, injury while on active duty, mild DDD and osteophytes, lumbar tenderness, non-focal neurological deficit, pain with ROM, condition existed prior to service, but was compensable under 10USC 1207A.  The VA assigned a 20% rating under the 5242 code (degenerative arthritis of the spine) based on the C&P examination citing back injury, DDD by MRI at L4-5, annular tear at L2-L3,  ROM, and  painful motion.  The ROM values in the PT exams were consistent with the 10% rating and the C&P examination ROM values were consistent with the 20% rating.  Recognizing the temporal relationship to the date of separation, the board considered the relative probative value of the proximate exams (PT and C&P).  The Board assigned more probative value to the PT examinations because they documented comprehensive and repetitive lumbar spine ROM measurements with a goniometer.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  While the NARSUM documented “left lower extremity radicular symptoms…,” the C&P examination documented “denied … pain radiation, numbness, paresthesia ….”  There was no evidence in this case that motor weakness or sensory impairment existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  While the proximate exams documented tenderness, there was no evidence of muscle spasm, abnormal spinal contour, or abnormal gait.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  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.

Left Ankle Condition.  According to the STR, the left ankle condition began approximately 7 years prior to referral for MEB.  The CI reinjured his left ankle while deployed.  Serial X-rays showed thickening of the distal tibia and heel and ankle bone spurs.  An MRI showed a probable anterior talofibular ligament (ATFL) tear.  In the NARSUM, the CI reported the pain and instability had improved with PT, muscle strengthening, a brace, and NSAIDs.  The physical examination documented a normal gait.  The left ankle examination revealed ATFL tenderness with normal foot and knee alignment.  The anterior drawer (assesses ATFL) test was stable and the talar tilt (assesses calcaneofibular ligament) test was mildly positive with no sense of instability.  Left ankle ROM was dorsiflexion of 10 (20) and plantar flexion of 40 (45) degrees.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings from the X-rays and MRI.  The diagnosis listed left ankle instability.  The surgeon opined that surgical treatment was not indicated.  Pain limited repetitive ROM, measured by PT with a goniometer, documented dorsiflexion was 15/15/15 (20) and plantar flexion was 50/50/50 (45) degrees.  In the C&P examination, the CI complained of progressively worse left ankle pain that was exacerbated by activity and weight bearing.  There was associated tenderness, weakness, stiffness, and decreased mobility.  The CI denied deformity, effusion, inflammation, giving way, instability, dislocation, subluxation (incomplete or partial dislocation), locking, or flare-ups.  The physical examination documented a normal gait.  Left ankle dorsiflexion was 15 (20) and plantar flexion was 40 (45) degrees.  There was no additional loss of motion on repetitive use.  Strength, sensation, and DTRs were normal.  An X-ray showed an anterior heel bone spur.  The diagnosis listed left ankle sprain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis) citing left ankle instability, pain, ROM loss of less than 10% compared to right ankle, small anterior osteophyte with no arthritis by radiographs, no neurovascular deficits, ATFL tenderness, stable anterior drawer, normal strength including peroneal strength, and rated for minimal and intermittent pain under US Army Physical Disability Agency pain policy.  The VA assigned a 10% rating under the 5271-5003 codes (limited motion of ankle-degenerative arthritis) based on the C&P examination citing left ankle roll type injury, pain, and X-ray evidence of calcaneal spur.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  The proximate (NARSUM, PT, and C&P) exams documented near normal plantar flexion (40, 50, and 40 degrees) and interval improvement to near normal dorsiflexion (10, 15, and 15 degrees).  Board members agreed that the ROM values were essentially normal and did not support a minimal rating under 5271 (ankle, limited motion of).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 left ankle condition, coded 5099-5003.

Right Knee Condition.  According to the STR and NARSUM, the right knee condition began approximately 1 ½ years prior to referral for MEB.  The CI twisted his right knee while deployed.  Serial X-rays showed degenerative changes, osteoarthritis, and minimal lateral patella subluxation.  An MRI showed chondromalacia patella (patellar cartilage abnormal softening/degeneration).  The CI underwent right knee arthroscopy which revealed chondromalacia.  Orthopedic surgery performed chondroplasty (surgical cartilage repair) with microfracture (subchondral bone breaching to form new cartilage).  Subsequent X-rays showed severe patellofemoral joint osteoarthritis.  In the NARSUM, the CI noted some improvement from surgery, though he continued to have painful mechanical symptoms and occasional swelling.  The physical examination documented a normal gait.  The right knee examination revealed pain with patellar compression, excellent quadriceps tone, and no effusion.  There was normal patellar tracking and knee alignment.  Active ROM was flexion of 140 (140) and extension of 0 (0) degrees.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings from the X-rays.  The diagnosis listed moderate chondromalacia of the right knee patellofemoral joint and medial femoral condyle.  Pain limited repetitive ROM, measured by PT with a goniometer, documented flexion was 130 (140) and extension was 0 (0) degrees.  In the C&P examination, the CI complained of pain, tenderness, weakness, and decreased mobility.  The physical examination documented a normal gait.  The right knee examination revealed subpatellar tenderness and grinding.  There was no clicks, snaps, instability, mass, meniscus abnormality, tendon abnormality, bursa abnormality, or other knee abnormality.  Active ROM values were flexion of 110 (140) and extension of 0 (0) degrees.  There was no additional loss of motion on repetitive use.  Strength, sensation, and DTRs were normal.  The right knee X-rays showed minimal joint space narrowing in the medial compartment.  The diagnosis listed right knee pain is due to chondromalacia patella.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis) citing right knee pain, injury while deployed in Iraq, chondromalacia of the medial femoral condyle, trochlea and patella, underwent arthroscopy and chondroplasty, ROM of 0-140 degrees, and no instability.  The VA did not service connect the right knee under the 5257 code (other impairment of knee) based on the C&P examination citing the condition neither occurred in, nor was caused by service.  The proximate (NARSUM, PT, and C&P) examinations did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261).  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 right knee condition, coded 5099-5003.

BOARD FINDINGS: In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Neck Pain	5299-5237	10%	
Chronic LBP	5299-5237	10%	
Left Ankle Instability	5099-5003	10%	
Right Knee Pain w/Injury	5099-5003	10%	
RATING (w/BLF)	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140207, 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, AR20160006648 (PD201400730)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with Reserve retirement.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with Reserve retirement.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with Reserve retirement.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with Reserve retirement.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA