RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01255
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080709

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Satellite Communication System Operator Maintainer, medically separated for “chronic low back pain,” “right knee,” “left knee,” and “bilateral hip pain,” rated 10%, 10%, 0%, and 0% respectively, with a combined disability rating of 20%.

CI CONTENTION:  His conditions were worse than what was rated by the PEB.  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 – 20080416	VARD - 20090210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Disc Disease, Lumbar Spine (L5-S1)	5243	20%	20081229	
Right Knee Pain	5099-5003	10%	Right Knee Arthritis	5003	10%		
Left Knee Pain	5099-5003	0%	Left Knee Arthritis	5003	10%		
Bilateral Hip Pain	5019	0%	Right Hip Arthritis with Labral Tear	5003	10%		
			Left Hip Arthritis with Labral Tear	5003	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s chronic low back pain (LBP) condition began in November 2004 after falling from a vehicle when his equipment became tangled during dismount.  A diagnostic imaging (MRI) study on 24 May 2006 showed a normal lumbar spine with no intervertebral disc herniation or impingement of nerve structures.  There was mild degenerative disc disease (DDD) at L4-L5 with a periarticular cyst noted on the left.  Diagnostic imaging (X-ray) studies performed 24 October 2007 showed mild thoracolumbar levocurvature (spine curving to the left) but otherwise normal thoracolumbar spine showing no intervertebral disc herniation or impingement of nerve structures.  An X-ray study on 23 January 2008 showed mild narrowing of the neuroforamina (nerve root opening) at L5-S1 level without bulging or herniated intervertebral discs.  An MRI study on 9 January 2009 was normal showing no intervertebral disc herniation or impingement of nerve structures.  There was severe DDD of the L5-S1 junction.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic low back pain” for PEB adjudication.

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	Spine Surgeon ~24 Mo. Pre-Sep
	PT (for MEB) ~5 Mo. Pre-Sep
	VA C&P ~6 Mo. Post-Sep
	
Flexion (90 Normal)	WNL	50/50/50	50	
Combined (240)	--	200	140	
Comments	Normal lumbar spine, diffuse, non-localizing tenderness 	Pain throughout ROM measurements	Limp on the right side	
§4.71a Rating	0%	20%	20%	

At the 28 January 2008 MEB examination, 5 months prior to separation, the CI reported a constant ache in his lower back (L>R).  The pain was rated 2/10 scale and flared to 10/10 many times throughout the day.  Pain was exacerbated by walking, standing, kneeling, and carrying heavy loads and relieved by rest.  Physical examination showed normal gait, sensation, and reflexes.  There was no muscle spasm and examination maneuvers for radicular signs were negative.  Thoracolumbar ROM after repetition was limited by pain as recorded in the chart.  At the 29 December 2008 VA Compensation and Pension (C&P) exam, 6 months after separation, the CI reported intermittent 10/10 low back pain.  The sharp, stabbing pain occurred daily, and lasted a few hours.  Associated symptoms were pain radiating into the upper back, stiffness, and numbness and tingling in both legs.  Pain was exacerbated by prolonged standing and sitting and relieved by time.  The physical examination documented an abnormal gait with a slight right-sided limp.  The spine examination revealed a normal contour with no tenderness.  Thoracolumbar ROM after repetition was limited as recorded in the chart.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10% coded 5237 (lumbosacral strain), citing limitation of motion with no radiculopathy or deformity.  The VA rated the LBP condition 20% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 6 months after separation, citing limitation of forward flexion.  The Board deliberated on the probative value of the examinations in evidence and the totality of the record.  The documented limitation of flexion at the PT (MEB) and VA C&P exams of forward flexion of 50 degrees following repetition were the two pieces of data in the record that reached the 20% criteria for forward flexion of the thoracolumbar spine of greater than 30 degrees but not greater than 60 degrees.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the PT (MEB) and VA examinations.  There was no documentation of incapacitating episodes which would provide for a higher rating under that formula.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported radiating pain down his legs documented in the treatment records in one emergency room visit January 2007.  However, by the time of separation, examinations indicated normal strength and reflexes.  The VA examination also did not indicate any motor or sensory deficits.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation specific activities.  There is no evidence in this case that motor weakness or sensory deficit existed to any degree that could be described as functionally impairing.  The Board therefore concludes that additional disability rating was not justified on this basis.  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 chronic low back pain condition, coded 5237.

Right Knee Condition.  According to the STR and NARSUM, the CI’s right knee pain condition began in February 2005 after running on several occasions.  Serial right knee X-rays were unremarkable.  A 23 January 2008 X-ray showed mild medial compartment narrowing.  An MRI on 9 January 2009 showed a trace joint effusion (fluid collection), chronic medial collateral ligament (MCL) strain, and minimal degenerative changes in the medial and lateral menisci.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral knee pain with patellofemoral syndrome” for PEB adjudication.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. 

Right Knee ROM
(Degrees)	Ortho ~16 Mo. Pre-Sep
	PT (for MEB) ~5 Mo. Pre-Sep
	VA C&P ~6 Mo. Post-Sep
	
Flexion (140 Normal)	125	100/100/100	120	
Extension (0 Normal)	0	0/0/0	0	
Comment	Normal gait/no swelling or effusion/ mild right prepatellar bursitis/pain with flexion but not extension motion	No effusion/tenderness to palpation/pain at end of flexion motion 	No swelling or effusion/tenderness on joint line/anterior drawer sign positive/McMurray’s is positive	
§4.71a Rating	10%	10%	10%	

At the NARSUM examinaiton, the CI reported sharp, throbbing pain in both knees.  The pain was intermittent throughout the day but occurred 2-14 hours daily.  Pain was exacerbated by walking, prolonged standing, kneeling, sitting, and stairs.  His knees would swell with excessive activity and occasionally lock up and completely giving out.  The physical examination documented a normal gait, normal patellar tracking, and no effusion.  The anterior/posterior drawer (assess anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]), Lachman (assess ACL), McMurray (assess menisci), and patellar grind (assess abnormal patellar movement and painful crepitation) tests were negative.  The CI had tenderness about the medial and lateral joint lines.  The ROM was mildly limited in flexion by pain as recorded in the chart.  At the C&P examination the CI reported intermittent knee pain rated at 10/10 scale occurring daily.  There was associated knee weakness, stiffness, and swelling.  He reported his knees had “locking and popping” sensations, tended to give way, and he had fallen as a result.  Pain was exacerbated by activity and prolonged sitting and relieved by time.  The CI did not use any walking aides or braces.  Physical examination showed an abnormal gait (slight limp to the right side).  There was joint line tenderness and tenderness on varus (away from body’s midline) and valgus (toward body’s midline) strain.  Anterior drawer sign and McMurray’s maneuver were positive.  The ROM was mildly limited in flexion as recorded in the chart. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% (coded 5099-5003, [arthritis, degenerative]), citing limitation of motion due to pain.  The VA also rated the right knee condition 10% (coded 5003, [arthritis, degenerative]), citing limitation of motion due to pain, based on the post-separation C&P exam.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (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.  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 right knee pain condition.

Left Knee Condition.  According to the STR and NARSUM, the CI’s left knee pain condition began in February 2005 after running on several occasions.  An MRI on 16 June 2006 showed a mild joint effusion and slight discoid contour of the medial meniscus without a tear.  Serial X-rays showed mild degenerative disease, but were otherwise unremarkable.  A repeat MRI on 9 January 2009 showed the medial and lateral menisci degeneration without a definite tear and a remote injury of the MCL.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “bilateral knee pain with patellofemoral syndrome” for PEB adjudication.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. 

Left Knee ROM
(Degrees)	Ortho ~16 Mo. Pre-Sep
	PT (for MEB) ~5 Mo. Pre-Sep
	VA C&P ~6 Mo. Post-Sep
	
Flexion (140 Normal)	125	120/120/120	120	
Extension (0 Normal)	0	0/0/0	0	
Comment	Normal gait/no swelling or effusion/ mild right prepatellar bursitis/pain with flexion but not extension motion	No effusion/tenderness to palpation/pain at end of flexion motion	No swelling or effusion/tenderness on joint line/anterior drawer sign positive/McMurray’s is positive	
§4.71a Rating	10%	10%	10%	

At the MEB NARSUM examination, the CI reported sharp, throbbing pain in both knees.  The pain was intermittent throughout the day but occurred 2-14 hours daily.  Pain was exacerbated by walking, prolonged standing, kneeling, sitting, and stairs.  His knees would swell with excessive activity and occasionally lock up and completely giving out.  The physical examination documented a normal gait, normal patellar tracking, and no effusion.  He had negative anterior drawer, posterior drawer, Lachman, McMurray, and patellar grind tests.  The CI had tenderness to palpation about the medial and lateral joint lines.  The ROM was mildly limited in flexion by pain as recorded in the chart.  At the C&P examination the CI reported intermittent knee pain rated at 10/10 scale occurring daily.  There was associated knee weakness, stiffness, and swelling.  He reported his knees had “locking and popping” sensations, tended to give way, and he had fallen as a result.  Pain was exacerbated by activity and prolonged sitting and relieved by time.  The CI did not use any walking aides or braces.  Physical examination showed an abnormal gait (slight limp to the right side).  There was joint line tenderness and tenderness on varus and valgus strain.  Anterior drawer sign and McMurray’s maneuver were positive.  The ROM was mildly limited in flexion as recorded in the chart. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0% (coded 5099-5003, [arthritis, degenerative]), citing normal range of motion.  The VA rated the left knee condition 10% (coded 5003, [arthritis, degenerative]), citing limitation of motion due to pain, based on the post-separation C&P examination.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 knee pain condition, coded 5003.  

Bilateral Hip Condition.  According to the STR and NARSUM, the bilateral hip condition began approximately 3 years prior to referral for MEB.  Serial left hip X-rays were unremarkable.  At an orthopedic surgery evaluation, the CI complained of 3 years of bilateral hip pain.  Pain was 5/10 at rest and up to 10/10 with activity.  The physical examination documented an antalgic (assuming a gait or posture to lessen pain) gait.  The bilateral hip examination revealed normal appearance, no instability, and tenderness of the greater trochanters (bony prominences on proximal lateral femur), trochanteric bursae (fluid-filled sacs near joint at lateral hip), and iliotibial band Iliotibial (IT) bands (lateral thigh thick connective tissue).  Right hip active ROM was flexion of 90 (125 normal), abduction of 30 (45), adduction of 25 (45), and external rotation of 60 (45), and internal rotation of 40 (45) degrees.  Left hip active ROM was flexion of 110 (125), abduction of 45 (45), adduction of 30 (45), and external rotation of 60 (45), and internal rotation of 40 (45) degrees.  Strength and sensation were normal.  The orthopedic surgeon performed steroid injections of the bilateral trochanteric bursae.  The assessment listed bilateral hip osteoarthritis, trochanteric bursitis (inflammation of the bursa), and iliotibial band syndrome ([ITBS] lateral knee overuse injury).  A bilateral hip MRI was unremarkable except for two benign-appearing right femoral neck foci (synovial herniation pits).  A bilateral hip and pelvis X-ray was unremarkable.  Physical therapy (PT) measured repetitive (X3) ROM with a goniometer.  Right hip active ROM was flexion of 90/90/90 (125), extension of 0/0/0 (20), and abduction of 30/30/30 (45) degrees.  Left hip active ROM was flexion of 100/100/100 (125), extension of 0/0/0 (20), and abduction of 45/45/45 (45) degrees.  The NARSUM, recounted the history and interventions.  The CI complained of gradual onset of bilateral hip pain with activity.  Steroid injections provided temporary relief and PT provided some back and knee benefits but exacerbated his hip pain.  The examiner noted the CI gained over 100 pounds over the preceding 3 years.  The CI was taking no medications for pain.  The physical examination documented a height of 71 inches and a weight of 349 pounds with a body mass index (BMI) of 48.7 (morbid obesity > 40.0).  The focused bilateral hip examination revealed tenderness over the greater trochanters.  The Stinchfield (assesses for intra-articular hip joint pathology) and log roll (assesses for intra-articular hip joint pathology) tests were negative.  The examiner cited the musculoskeletal examination by the orthopedic surgery, the formal ROM measurements by PT, and the X-ray findings.  The diagnosis listed bilateral hip pain with trochanteric bursitis.  A right hip MRI showed a labral tear (anterior superior) and a left hip MRI showed a possible labral tear (posterior).  The C&P examination recounted the history and intervention.  The CI complained of a 6-year history of intermittent 8/10 bilateral hip pain with associated stiffness and locking and popping sensations.  He reported he gained about 125 pounds over 3 years and this increased pain in all his joints and limited his ability to exercise or do any physical activity.  Pain was exacerbated by prolonged sitting and activity and relieved by time.  He denied flare-ups or use of any assistive devices.  The physical examination documented a height of 71 inches and a weight of 350 pounds (morbid obesity by BMI) and a slight limp to the right.  The bilateral hip examination revealed no swelling, erythema (redness), or effusion (fluid collection).  Right hip active ROM was flexion of 50 (125), extension of 15 (20), abduction of 30 (45), adduction of 20 (45), internal rotation of 20 (45), and external rotation of 40 (45) degrees.  Left hip active ROM was flexion of 45 (125), extension of 15 (20), abduction of 30 (45), adduction of 20 (45), internal rotation of 20 (45), and external rotation of 30 (45) degrees.  There was no further limitation in ROM with repetitive activity due to weakness, instability, fatigue, or lack of coordination.  The examiner recounted the findings of the MRIs.  The assessment listed bilateral hip condition due to arthritis. 

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each hip condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under the 5019 code (bursitis) citing bilateral hip pain due to trochanteric bursitis, had not responded to conservative therapy, without significant loss of hip joint motion aside from that due to body habitus, and rated as bursitis.  The VA assigned a 10% rating for the right hip, and a 10% rating for the left hip, under the 5003 code (degenerative arthritis) based on the C&P examination 6 months after separation.  For the bilateral hips, the VA cited arthritis, labral tear, painful or limited motion of a major joint, ROM, and no additional limitation in ROM on repetitive testing due to weakness, fatigue, lack of endurance, or incoordination.  There was no evidence of disability for consideration of rating under 5250 (hip, ankylosis of), 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of), 5253 (thigh impairment of abduction, adduction, rotation of), 5254 (hip, flail joint), or 5255 (femur fracture nonunion/malunion of).  Members debated if 0% was warranted for the bilateral hips or if application of VASRD §4.40 (functional loss) or §4.59 (painful motion) justified a 10% ratings.  The Board carefully considered the option of rating both hip conditions together, noting that the VA rated each hip separately.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate hip disability ratings in this case, and that a bilateral rating of 10%, coded 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 recommends a disability rating of 10% for the bilateral hip condition. 

BOARD FINDINGS:  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 right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the bilateral hip condition, the Board unanimously recommends a disability rating of 10%, coded 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	PERMANENT RATING	
Chronic Low Back Pain 	5237	20%	
Right Knee Pain 	5003	10%	
Left Knee Pain 	5003	10%	
Bilateral Hips 	5003	10%	
COMBINED	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR2016001 0064 (PD201401255)

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 50% effective the date of the individual's original medical
separation for disability with severance pay.

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 severance pay.

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

        c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will
account for recoupment of severance pay, and payment of permanent retired pay at
50% effective the date of the original medical separation for disability with severance
pay.

        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
( ) OVA