RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01599
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Infantryman, medically for “chronic back pain” and “left knee pain” rated at 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The VA granted him higher ratings for his conditions and there were conditions not discovered at separation.  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 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 - 20040902	VARD - 20070918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain…	5299-5242	10%	Low Back Strain with…DJD	5242-5237	10%	20070813	
Pain Left Knee 	5099-5003	0	Left Knee Chondromalacia	5261-5020	10%	20070813	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s longstanding  back pain condition was aggravated in January 2003 due to field conditions and the type of compartment he was confined in as a Bradley gunner.  He denied specific trauma.  An orthopedic evaluation on 28 October 2003 documented a normal posture without spasm.  Flexion was reduced at 70 degrees (90 normal) and extension was reduced to 10 degrees (30 normal).  His neurological examination was normal.  Radiographic (magnetic resonance imaging [MRI]) studies done in November 2003 showed a small annular tear (disc) at L4-5 and facet (part of the vertebral body) changes from L3-4 and L5-S1.  At the time of the orthopedic clinic appointment on 20 November 2003, there was no change in the examination.  The examiner opined that the CI should not return to his regular military service.  The MEB NARSUM examination was perfomed on 3 August 2004, approximately 4 months prior to separation, and documented constant low back pain with occasional flares.  The CI denied any radicular pain.  The physical examination findings are summarized in the chart below.  There were functional limitations of an inability to run, heavy lifting, marching or rucking.  He had a painful gait, but used no assistive device.  Two maneuvers not expected to produce pain were painful.  Tenderness was present, but neither spasm nor guarding were recorded.  Loss of normal lumbar curvature was present.  The range of motion (ROM) was painful and reduced as charted below.  The reflexes were normal.  The sensory and motor examination was not documented.  Provocative testing for nerve root irritation was positive on the left when seated and bilaterally while supine.

At the VA Compensation and Pension (C&P) examination dated 13 Aug 2007, performed approximately 33 months after separation, the CI reported constant low back pain.  On examination, the gait and neurological examinations were normal.  Guarding, tenderness, and spasm were absent.  Provocative nerve root testing was negative.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating coded 5299-5242 (analogous to degenerative arthritis of the spine); citing pain limited ROM, with localized tenderness.  The VA assigned a 10% rating coded 5242-5237 (degenerative arthritis of the spine - lumbosacral strain) based on the VA C&P examination approximately 33 months after separation, citing increased functional impairment and decreased ROM during periods of flare-up and with repetitive motion.

The Board agreed that a 10% rating was supported by painful and limited motion, but found no route to a higher 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 chronic back pain.

Left Knee Pain.  The CI underwent radiographic (MRI) studies in October 2003 for a several year history of left knee pain which had not resolved with conservative management including duty restictions and medications.  The MRI showed mild chondromalacia of the patella without any internal derangement.  The MEB NARSUM examination on 3 August 2004, approximately 4 months prior to separation, noted complaints of minor knee pain.  The physical examination showed painful compression and an abnormal gait.  The ROM, charted below, was painful and limited, but the knee was stable and signs of meniscal irritation absent.  There were functional limitations of an inability to run, heavy lifting, marching or rucking.

At the VA Compensation and Pension (C&P) examination dated 13 Aug 2007, performed approximately 33 months after separation, the CI reported chronic daily knee pain related to position and activity.  He had a normal gait, but used his arms to rise from a squatting position.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating coded 5099-5003(analogous to arthritis, degenerative), citing the USAPDA pain policy.  The VA assigned a 10% rating coded 5261-5020 (leg, limitation of extension - synotivitis), based on the VA C&P examination 33 months after separation, citing §4.7 (higher of two evaluations), with consideration given to increased functional impairment and decreased ROM during periods of flare-up and repetitive motion.

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.

BOARD FINDINGS:  In the matter of the chronic back pain and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee pain, 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, effective as of the date of the prior to medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Back Pain	5299-5242	10%	
Left Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140407, 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 XXXXXXXXXXXXXXXXXXXXX AR20160007305 (PD201401599)

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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA