RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00824
BRANCH OF SERVICE:  Army 	BOARD DATE: 20140911
SEPARATION DATE:  20070902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (92F10/Petroleum Specialist) medically separated for chronic low back pain, bilateral shin splints and bilateral knee pain.  The back, bilateral knees and shin splint conditions 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).  “Lower back pain,” “bilateral shin splints” and “bilateral knee pain,” were forwarded by the MEB 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, bilateral shin splints and chronic bilateral knee pain as unfitting, rated at 10%, 0% and 0%, respectively with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) for the back and shin splints, but adjudicated the knees citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI did not concur and an Informal Reconsideration increased the rating for the bilateral knee condition to 10% (still utilizing the Pain Policy).  The CI concurred and was medically separated.

CI CONTENTION:  The CI wrote, “Because after being discharged from the Army, the VA rated me 40% for the same condition within the same year or months later.”

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 ratings for the unfitting back, bilateral shin splints and bilateral knee conditions are 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.

RATING COMPARISON:  

Service Informal Recon – Dated 20070531	VA - (4 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Lumbar Strain	5237	40%	20080113	
Chronic Bilateral Knee Pain	5099-5003	10%	Bilateral Knee Pain	5099-5003	NSC	20080113	
Shin Splints	5022	0%	Bilateral Shin Splints	5022	NSC	20080113	
Other x 0 (Not is Scope)	Other x 3		
Combined Rating:  20%	Rating:  40%	
Derived from VA Rating Decision (VARD) dated 20080313 (most proximate to date of separation).

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate service members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Chronic Low Back Pain.  The CI first presented for care of low back pain on 22 August 2006 and reported gradual onset without a specific injury.  The pain was worsened with exercise, bending and lifting without radiation of pain.  On examination there was no spasm and range-of-motion was full.  X-rays of the lumbosacral spine were normal.  The CI aggravated her back in a fall while at the gym 29 August 2006 and examination noted pain with motion.  Orthopedic evaluation of the back dated 5 September 2006, recorded complaint of intermittent back pain radiating into the legs.  Thoracolumbar range-of-motion (ROM) was “full” but there was “some mild pain” with flexion.  Magnetic resonance imaging of the lumbosacral spine dated 20 September 2006, was normal (no degenerative disc disease, herniated discs or nerve compression).  Clinic appointments in October and November 2006 recorded persistent low back pain, aggravated by prolonged standing while performing guard duty and gate duty.  The MEB narrative summary, dated 21 February 2007, noted 5 months of low back pain without any specific injury which was unimproved by treatment.  On examination, the back was tender and there was pain with motion.  Motion was limited by report of pain to 58 degrees of flexion, 14 degrees of extension and approximately 45 degrees of lateral bending and rotation in both directions.  Contemporaneous examinations noted normal gait.  Physical medicine and rehabilitation evaluation on 14 May 2007, noted low back pain without radiation, aggravated by prolonged standing, lifting and bending.  The back was reported as showing no abnormalities and gait was normal.

At the time of the VA Compensation and Pension (C&P) examination on 17 October 2007, a month after separation, the CI was 9 months pregnant and a full back examination was not performed.  Gait and posture were normal.  At the VA C&P examination on 13 January 2008, following delivery of her child, the gait was normal but slow.  There was pain reported with all touching of the back.  The CI flexed to 60 degrees with report of pain beginning at 30 degrees.  Lateral flexion was 20 degrees and rotation 30 degrees with report of pain throughout.  The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back pain at 10% (coded 5237, lumbosacral strain), citing pain limited motion.  The VA rated chronic lumbar strain (coded 5237) at 40% citing thoracolumbar flexion of 30 degrees from the January 2008 VA C&P examination.  The Board noted the January 2008 VA C&P examination reflected significantly worsened complaint of back pain since separation and the examination recorded dramatically worsened tenderness to all touch that was not present prior to separation.  The CI had recently delivered her child.  The Board agreed this examination was not reflective of the overall disability picture at the time of separation and was inconsistent with the evidence of the service treatment records (STR).  The Board discussed the ROM examinations in the STR that varied from full motion to flexion limited to 60 degrees.  Thoracolumbar flexion limited to 60 degrees is the threshold for a 20% rating under the VASRD general rating formula for diseases and injuries of the spine.  The Board discussed the prior examinations reporting “full” ROM as well as the normal imaging showing no specific abnormality that would be associated with back pain.  The Board noted the examinations reflecting 60 degrees of flexion were more proximate to separation and concluded that the evidence was in equipoise regarding the 10% versus the 20% rating.  The Board noted the VA rating decision granting 40% cited limitation of motion at 30 degrees; however the C&P examination demonstrated flexion to 60 degrees with painful motion which more nearly approximates the 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the low back pain condition (5237).
Bilateral Knee Pain.  Review of the STR show care for bilateral anterior knee pain in August 2005 while the CI was in basic training.  Following this time, the STRs document complaints of shin and leg pain, but not pain localized to the knees.  Clinic records from February 2006 and April 2006 refer to shin pain with running, but not knee pain.  At a pre-deployment health assessment on 9 June 2006, the CI complained of leg numbness and pain when running.  Orthopedic evaluation in June 2006 recorded shin pain but not knee pain.  Orthopedic examination 12 June 2006, documented a normal knee examination with full ROM and normal gait.  Clinic examination on 6 October 2006 recorded a normal knee examination with normal gait.  At the time of the MEB history and physical examination on 26 January 2007, the CI reported bilateral knee pain described as feeling like something was going to pop out the back of her knee when walking.  Clinic examination on 6 February 2007 recorded complaint of pain below the knee with a normal knee examination and normal gait.  The MEB NARSUM dated 21 February 2007, reported bilateral knee pain and shin pain since basic training without trauma.  On examination, there was tenderness of the anterior knees.  The knees flexed to 140 degrees and extended to 10 degrees with report of pain.  The physical medicine and rehabilitation evaluation on 14 May 2007, recorded shin pain, thigh numbness and pain that radiated to the knees.  Examination of the knees was normal and gait was normal (normal gait requires full normal knee extension).

At the VA C&P examination, 17 October 2007, a month after separation, the gait was normal.  The CI was 9 months pregnant and a full extremity examination was not performed.  At the VA C&P examination dated 13 January 2008, following delivery of her child, the CI did not describe knee pain but reported diffuse leg pain and numbness.  On examination, the gait was normal but slow.  There was pain reported with all touching of the legs including the knees.  The knees were not examined because of CI report of extreme tenderness to touch.  The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral knee pain 10% (coded 5099-5003) with application of the USAPDA pain policy noting normal examinations and imaging.  The VA determined the history of knee pain was not service-connected because the VA C&P examination did not record symptoms that localized to the knees or document a permanent or residual disability of the knees separate from the generalized lower extremity complaints.  Although the PEB determined the bilateral knee pain was unfitting, the Board did not find evidence of the STRs that showed a knee condition that was unfitting separate from the generalized lower extremity pain diagnosed as shin splints.  The STRs document shin pain due to shin splints as the limiting condition; not knee pain.  The Board further concludes that the bilateral knee pain condition would not warrant a rating more than 0% (either bilateral or individually) since examinations were normal and there was not pain that localized to the knees.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that the preponderance of evidence supported no higher than a 0% rating for each knee.

Bilateral Shin Splints.  The CI presented to the clinic on 3 February 2006 with complaint of bilateral shin pain for 2 months.  There was no injury and pain was aggravated by activity.  There was tenderness, but the examination was otherwise unremarkable with normal gait.  X-rays of the legs were normal.  At a follow-up appointment on 4 April 2006, shin pain was improved and characterized as mild when running.  At a Pre-Deployment Health Assessment dated 9 June 2006, the CI complained of leg numbness and pain when running and she was referred for orthopedic evaluation.  Orthopedic examination performed on 12 June 2006 recorded complaint of bilateral leg numbness and pain with activity for 6 months.  On examination there was leg tenderness.  The neurovascular examination and gait were normal.  Bone scan obtained on 19 June 2006, demonstrated increased uptake in both shin bones (tibia) consistent with shin splints (no changes for stress fracture).  The orthopedic surgeon (22 June 2006) diagnosed shin splints and advised limitation of activities.  Service treatment records document persistent complaint of leg pain and numbness with prolonged standing.  Record entries from October 2006, November 2006, and January 2007 reported symptoms were aggravated by guard and gate duty.  Examinations recorded tenderness with otherwise normal examination and normal gait.  Records indicate that by February 2007, the CI was no longer performing guard duty and was performing sedentary administrative duties (commander’s statement).  A second opinion examination by internal medicine performed on 6 February 2007, recorded localization of pain below the knees with paresthesia of the feet.  The examination was unremarkable with normal gait.  An emergency room examination performed 17 February 2007 (for abdominal pain), recorded a normal gait with non-tender lower extremities.  The MEB NARSUM dated 21 February 2007, recorded bilateral knee pain and shin pain since basic training without injury.  On examination, the legs were non-tender.  A neurology evaluation dated 18 April 2007, recorded leg pain since basic training with recurrence in January 2006 while running.  The neurologic examination was normal including strength and gait.  The neurologist concluded there was no neurologic basis for the leg symptoms.  The physical medicine and rehabilitation examination obtained on 14 May 2007, recorded history of shin pain with numbness.  However at the time of that examination, the CI reported tingling of the legs from the waist down to the anterior thighs with pain mostly in thighs which radiated to the knees.  Symptoms were worse with prolonged standing or sitting.  On examination, there was tenderness of the lower legs.  The neurologic examination was normal and the gait was normal.  The physical medicine physician thought the thigh numbness was consistent with compression of the lateral femoral cutaneous nerve at the waist (meralgia paresthetica) which is typically caused by constricting clothing (tight belt), obesity, or pregnancy (the CI was  approximately 5 months pregnant at this time).  The condition is limited to sensory symptoms and there are no muscular / motor impairments.

The VA C&P examination dated 17 October 2007 was a limited examination since the CI was 9 months pregnant.  Gait was normal.  At the VA C&P examination performed 13 January 2008, following delivery of her child and 4 months after separation, the CI did not describe symptoms of shin splints and had not sought treatment for shin splints.  The CI was concerned she had a nerve problem with her legs and reported diffuse leg pain and numbness.  The examiner noted her reported symptoms did not correlate with a known peripheral nerve distribution.  On examination, the gait was normal but slow.  There was pain reported with all touching of the legs including the knees.  There was no sensory deficit identified.  Strength and reflexes were normal.  The examiner commented that the reported symptoms were not consistent with the previous normal imaging and evaluations.  The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral shin splints 0% (coded 5022 periostitis) citing full motion.  The VA determined the shin splints and lower extremity numbness were not service connected because the VA C&P examination did not document a permanent or residual disability.  The STRs document chronic complaints of lower leg pain diagnosed as shin splints between January 2006 and the MEB NARSUM in February 2007.  Prior to February 2007, the CI was performing guard and gate duty requiring prolonged standing.  However by February 2007 she was reassigned to sedentary duties and at the time of the MEB NARSUM, the CI’s lower legs were non-tender.  At the physical medicine and rehabilitation examination performed on 14 May 2007, thigh symptoms predominated.  At the January 2008 VA C&P examination, symptoms of shin splints were not described.  Improvement of shin splints is expected when aggravating strenuous activities such as running or prolonged standing are limited.  The Board discussed the apparent improvement after February 2007 and concluded a rating higher than the 0% rating (bilateral or unilateral) adjudicated by the PEB was not supported at separation.  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 shin splint 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the chronic bilateral knee pain condition, the Board unanimously recommends a disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the shin splints condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain Atraumatic Onset	5237	20%	
Chronic Bilateral Knee Pain	5099-5003	0%	
Bilateral Shin Splints	5022	0%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

SAMR-RB									

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20150006629 (PD201400824)

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 description without modification of the combined rating or 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						

CF: 
(  ) DoD PDBR
(  ) DVA