RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00904
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20081104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Maintenance Journeyman, medically separated for “chronic low back pain with mild disc protrusion at L4-5” and “chronic bilateral knee pain, patellofemoral syndrome,” rated 10% and 10%, respectively, with a combined disability rating of 20%. 

CI CONTENTION:  She was given a higher rating for her back condition by the VA.  Her 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 - 20080912	VARD - 20090423	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain With Mild Disc Protrusion At L4-5	5243	10%	Lumbosacral Strain	5237	10%	20090317	
Chronic Bilateral Knee Pain, Patellofemoral Syndrome	5099-5003	10%	Patellofemoral Pain Syndrome, Right Knee	5257	10%		
			Patellofemoral Pain Syndrome, Left Knee	5257	10%		
COMBINED RATING:  20%	COMBIEND RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back pain began approximately 1 year prior to referral for MEB.  A lumbar spine X-ray was within normal limits with possible mild structural scoliosis (abnormal lateral spine curvature).  A thoracic spine MRI was negative.  Over serial physical therapy (PT) encounters, lumbar flexion increased from 30 to 48 to 60 (90 normal) degrees.  Repetitive range of motion (ROM) was measured by PT for the MEB.  The thoracolumbar active ROM was flexion of 55/50/45 (90), extension of 20/20/20 (30), right lateral flexion of 25/20/20 (30), left lateral flexion of 20/15/18 (30), right rotation of 40/40/45 (30), and left rotation of 40/45/45 (30) degrees.  The spine orthopedic surgery evaluation documented the physical examination was negative except for low back pain with limited movement.  A left straight leg raise (SLR) test (assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) was mildly-positive.  The surgeon reviewed the MRI and observed a midline disc bulge at L4-5.  He opined that the disc bulge at L4-5 was causing the back pain and that no surgery or aggressive treatment was indicated.  A follow-up PT encounter documented lumbar flexion of 0-72 (90) degrees.  Pain management performed multiple lumbar epidural steroid injections (ESIs) for lumbar radiculitis and a blood patch for a cerebrospinal fluid (CSF) leak.  The NARSUM, 4 months before separation, recounted the history and interventions.  The CI reported onset of back pain with no known injury.  She complained of chronic low back pain with muscle spasm and cramps in the back and thighs.  Pain was associated with left leg tingling, numbness, and weakness.  The CI failed conservative management (activity modification, chiropractic manipulation, PT, and medications) and no surgery or aggressive treatment was indicated.  Active medications were Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), and a muscle relaxant (Flexeril).  The physical examination documented no tenderness observed on ambulation.  The back examination revealed spinous process (T10 to L3) and lumbar paraspinous muscle tenderness.  Appearance was normal and there was no muscle spasm or step deformity noted.  There was normal ROM and no pain elicited by rotation, flexion, or extension of the back.  Reverse straight leg raise (SLR) tests (assesses for herniated disc causing femoral nerve root [L2-L4] radiculopathy) were negative.  The deep tendon reflexes (DTRs) were normal.  The examiner referred to the PT ROM measurements for the MEB and the orthopedic surgery and pain management evaluations.  The examiner recounted the findings of the lumbar spine X-rays and MRIs.  The diagnosis listed lumbago.  A lumbar spine X-ray was normal except for mild scoliosis.  The Compensation and Pension (C&P) spine examination recounted the history and interventions.  The CI complained of daily pain from her bra line down the center to the lumbar area, sides, and tailbone.  Pain was characterized as severe, sharp, throbbing, and crampy with spasms.  Symptoms lasted hours to days and occurred weekly to monthly.  She received ESIs every 3 months and they provided relief for about 2-1/2 months.  Pain was exacerbated by activity, walking, prolonged standing, and prolonged sitting and relieved by medications (ESIs, Naproxen, Flexeril, Tylenol, Lidoderm Patches, and Icy Hot).  The CI denied a history of spinal trauma, urinary incontinence, fecal incontinence, radiation of pain, numbness, paresthesias, falls, unsteadiness, stiffness, weakness, flare-ups, incapacitating episodes, or use of devices/aids.  The physical examination documented a normal gait and posture.  The thoracolumbar spine examination revealed normal symmetry with no abnormal spinal curvatures, ankylosis, muscle spasm, atrophy, weakness, guarding, tenderness, or pain with motion.  There was no muscle spasm, localized tenderness, or guarding severe enough to cause an abnormal gait or abnormal spinal contour.  The SLR (Lasegue's) tests were negative.  The thoracolumbar active ROM was flexion of 0-75 (90), extension of 0-15 (30), right lateral flexion of 0-23 (30), left lateral flexion of 0-25 (30), right rotation of 0-28 (30), and left rotation of 0-26 (30) degrees.  There was evidence of pain on active ROM with no additional limitations after three repetitions of ROM.  Strength, sensation, and DTRs were normal.  The diagnosis listed degenerative disease of the lumbar spine.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5243 code (intervertebral disc syndrome) citing chronic low back pain with mild L4-5 disc protrusion.  The VA assigned a 10% rating under the 5237 code (lumbosacral strain) based on the VA C&P examination 4 months after separation citing back injury, normal reflexes, ROM, painful ROM, and no additional limitation of ROM upon three repetitions.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  While the CI may have experienced radiating left leg tingling and numbness from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  The Board concluded an additional disability rating was not justified on this basis.  While the ROM values measured by PT for the MEB were consistent with the 20% rating, subsequent PT and the C&P examination measurements were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The Board agreed the most proximate source of comprehensive evidence on which to base the permanent rating recommendation is the C&P examination, 4 months after separation.  While the NARSUM examination documented tenderness, there was no muscle spasm.  The C&P examination documented a normal gait with no tenderness, muscle spasm, guarding, or abnormal spinal curvature.  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.

Bilateral Knee Condition.  According STR and the NARSUM, the bilateral knee pain began approximately 2 years prior to referral for MEB.  The bilateral knee X-rays showed possible bilateral patellar tilt and possible patellar tendon inflammation.  Knee active ROM was measured by PT for the MEB.  Right knee ROM was extension of 0 to flexion of 130 (0-140 normal) and left knee ROM was extension of 0 to flexion of 135 (0-140) degrees.  At an orthopedic surgery evaluation the CI complained 2 years of persistent bilateral anterior knee pain.  The 6/10 pain developed while walking on unleveled ground and she denied a history of trauma.  Pain was exacerbated by prolonged sitting, standing, walking, and running and relieved by medication, limiting activity, and keeping her knees “moving a little bit.”  The CI did not experience significant relief from conservative management (activity modification, PT, home-based rehabilitation protocol, and medications).  Active medications were NSAIDs (Naprosyn, Ibuprofen) and a muscle relaxant (Flexeril).  The bilateral knee examination revealed intact skin and tight hamstrings with no lesions or effusion (fluid collection).  There was tenderness in the patellofemoral articulations.  The patellar grind (assesses abnormal patellar movement and painful crepitation) tests were positive and the quadriceps apprehension (apprehension or pain on quadriceps contraction with patella displaced) tests reproduced the CI’s symptoms.  The Lachman (assesses anterior cruciate ligament [ACL]) tests were 1A (< 5mm translation/firm endpoint) and the valgus/varus stress (assesses medial collateral ligament [MCL]/lateral collateral ligament [LCL]) tests were negative.  Bilateral knee active ROM was extension of 0 to flexion of 145 (0-140) degrees.  Sensation and pulses were normal.  Bilateral knee X-rays were normal.  The impression listed bilateral patellofemoral syndrome ([PFS] symptom complex of anterior knee pain involving the patella).  The surgeon recommended a long-term course of PT.  In the NARSUM the CI complained of chronic bilateral knee pain, with onset while deployed to Iraq, and with no known injury.  She failed conservative management (activity modification, PT, and medications) and active medications were Naproxen and Flexeril.  The physical examination documented no tenderness observed on ambulation.  The bilateral knee examination revealed full ROM with no pain with ROM.  The examiner referred to the PT ROM measurements for the MEB, the orthopedic surgery evaluation, and the findings of the bilateral knee X-rays.  The diagnosis listed bilateral PFS.  A left knee MRI showed a minimal joint effusion, a possible impingement, and possible bone marrow edema.  A right knee MRI showed a minimal joint effusion and possible bone marrow edema.  An orthopedic surgery bilateral knee examination revealed no effusion, no patellar maltracking, and no lower extremity weakness.  There was atrophy to the vastus medialis obliquus bilaterally.  There was diffuse tenderness over the fat pads and with compression of the patellofemoral joints.  The valgus/varus stress, quadriceps apprehension, and anterior/posterior drawer (assesses anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]) tests were negative.  The examiner recounted the findings of the bilateral knee X-rays and MRIs.  The assessment listed bilateral anterior knee pain.  The surgeon recommended long-term weight loss and PT as there was no good surgical option for her problems.  At the joint C&P examination the CI complained of intermittent bilateral knee pain with remissions.  She reported having pain about 1 week out of a month and was not under any specific treatment for PFS.  Pain was exacerbated by activity (standing, walking) but was never more than a 5/10 in intensity.  The CI denied knee deformity, giving way, instability, stiffness, weakness, incoordination, dislocations, subluxations, locking, effusions, inflammation, or flare-ups.  The physical examination documented a normal gait and no assistive devices/aids.  The bilateral knee examination revealed tenderness with no bumps (Osgood-Schlatter's disease), ankylosis (joint stiffening or immobility), crepitation (grating sound or sensation), masses, clicks, snaps, grinding, or instability.  There were no patellar, meniscus, tendon, or bursa abnormalities.  Bilateral knee active ROM was extension of 0 to flexion of 140 (0-140) degrees.  There was no pain with ROM and no additional limitations after three repetitions of ROM.  Bilateral knee X-rays were normal except for lateral tilting of the patellae.  The diagnosis listed bilateral PFS.

The Board directed attention to its rating recommendation based on the above evidence.  The Board must first consider whether each knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a bilateral 10% rating under an analogous 5099-5003 code (degenerative arthritis) citing chronic bilateral knee pain and patellofemoral pain syndrome.  The VA assigned a right 10% rating and a left 10% rating under 5257 (knee, other impairment of) based on the VA C&P examination 4 months after separation.  The VA cited 5/10 pain, 12 week per month, no bumps (Osgood-Schlatter's disease), ankylosis, crepitation, masses, clicks, snaps, grinding, instability, patellar abnormalities, meniscus abnormalities, tendon abnormalities, bursa abnormalities, full ROM, no pain with ROM, no additional limitations after three repetitions of ROM, and X-rays showing some lateral subluxation of the patellae.  While a knee condition (medical conditions) was not specifically implicated in the commander’s statement, knees were implicated by the profile officer in a medical clearance.  The bilateral knees were implicated in the NARSUM, MEB, and PEB.  It remains that both knees were considered to fail retention standards.  The disability attendant to only the right or left knee cannot be isolated by the clinical evidence, or extricated from the fitness implications of the bilateral limitations.  Members agreed that the right and left knee conditions should be considered as separately unfitting.  The proximate examinations did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  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.  Members debated if a 10% ratings was warranted for the bilateral knees with application of VASRD §4.40 (functional loss) or §4.59 (painful motion).  The Board carefully considered the option of rating both knees separately, noting that the VA rated the knees separately.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate knee disability ratings in this case, and that a bilateral rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 bilateral knee condition.

BOARD FINDINGS:  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 bilateral knee 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.  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 20140904, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00904.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings