RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		 CASE:  PD-2014-01746
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Health Care Specialist, medically separated for “chronic bilateral knee pain…” and  “chronic low back pain…”, rated 10% and 0% respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contends his conditions continue to worsen since separation.  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 based upon a 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 - 20031121	VARD - 20040504	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	10%	Patellofemoral Pain, Right Knee	5299-5260	10%	STR	
			Patellofemoral Pain Syndrome, Left Knee	5299-5260	0%	STR	
Chronic Low Back Pain…	5299-5237	0%	Mechanical Low Back Pain	5299-5237	0%	STR	
Right Hip Tensor Fascia Lata Muscle Strain	Not Unfitting	Tensor Fascia Lata Muscle Strain with Meralgia Paresthetica, Right Hip	8520-5252	10%	STR	
Meralgia Paresthetica	Not Unfitting					
Benign Granulomatous Disease of the Lungs, Mediastinum and Spleen	Not Unfitting	Benign Granulomatous Disease of the Lungs, Mediastinum and Spleen	6820	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition began in March 2003 after a fall from a military vehicle, although he had intermittent knee pain in 2002 after running or road marching.  He was medically evacuated from Iraq in April 2003 for evaluation of his knees and right hip (see below).  Treatment consisted of Tylox (a combination of oxycodone, a narcotic, and acetaminophen, a pain reliever) and naproxen (a non-steroidal anti-inflammatory drug (NSAID)) along with physical therapy for the knee pain.  X-rays in 2003 demonstrated normal knees bilaterally.  At an orthopedic evaluation in June 2003, the CI was noted to have patellofemoral pain syndrome (PFPS), right greater than the left, with normal tracking, a positive grind test, tenderness to palpation of the lateral facet, and a full range of motion (ROM).  

At the MEB examination in September 2003, 6 months prior to separation, the CI reported right and left knee pain for which he was given shoe inserts to try to relieve knee pain.  Physical examination showed positive Lachman’s and anterior drawer tests (for determination of laxity) and a mildly positive anterior drawer test of the left knee.  On examination in October 2003 the CI had tenderness over the medial patellofemoral joint line of the right knee that reproduced his symptoms.  The patella (kneecap) was slightly hypermobile and the patellar entrapment test was negative.  There was no instability and there was a full ROM.  No tibiofemoral joint line tenderness medially or laterally was present.  Motor strength was 5/5 on flexion and extension.  His symptoms, marked by intense pain, were reported with high impact activities and squatting and were significantly exacerbated by any running or climbing activities.  A brace was ordered in October 2003 to alleviate the symptoms of the PFPS.  

No VA Compensation and Pension (C&P) examination was performed proximate to separation and the VA Rating Decision (VARD) was based on STRs.  At an Emergency Room visit in August 2006, 29 months after separation, the CI reported left knee pain for 1 day.  X-rays were normal and he was given an elastic knee brace and Motrin (ibuprofen, an NSAID) for pain.  In November 2006 he had physical therapy for the knee pain.  X-rays of both knees were normal in January 2007.  A remote VA C&P examination with little or no probative value was performed on 11 January 2007, 34 months after separation.  The CI reported increased pain since discharge and as a result he avoided bending, crawling, and kneeling.  He had not seen a specialist in years.  On examination he had a normal gait.  ROM measurements were 0-135 degrees on the left and 0-125 degrees on the right.  Cruciate ligaments were intact and there was no meniscal pain, subluxation or a McMurray click (to determine a meniscal tear).  However, there was an audible click of the patellar tendon, worse on the right than the left, with direct pressure or when the knee went from flexion to extension.  The examiner opined that most of the CI’s knee problem was directly related to the patellofemoral surfaces, and there was probably evidence of chondromalacia as well.  

The 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.  

Knee ROM
(Degrees)	PT ~5 Mos. Pre-Sep	VA C&P ~34 Mos. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	140*	140*	135	125	
Extension (0 Normal)	-5	-5	0	0	
Comment	*Soft tissue approximation	Audible click of the patellar tendon with pressure, worse on the right than the left.	
§4.71a Rating	PEB 10%	VA 0%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis) citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA assigned a 10% rating for the right knee using an analogous 5299-5260 code (leg, limitation of flexion) based on the VA C&P examination 34  month after separation, citing patellofemoral pain, right knee and a 0% rating using and analogous 5299-5260 citing patellofemoral pain syndrome, left knee.

The PEB combined the right and left knee conditions under a single disability rating, coded 5099-5003 and rated 10% with application of the USAPDA pain policy AR 635-40.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was directed at determining whether the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left knee conditions were presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

The Board first considered whether the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting.  Members agreed that the right knee condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating. After due deliberation, and considering all of the evidence, the Board recommends a separately unfit determination with a disability rating of 10% for the right knee condition.  The Board then considered whether the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting.  Members agreed that the left knee condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating. After due deliberation, and considering all of the evidence, the Board recommends a separately unfit determination with a disability rating of 0% for the left knee condition.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257) except for a mildly positive drawer test noted only one time, 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).  No additional functional limitation was evidenced by the examinations.  The Board noted that in determining each knee as separately unfit and coded 5299-5260, which was used by the VA, is a better description of the condition, but provides no rating advantage.  Therefore the Board concluded there was not sufficient evidence to support a rating higher than the 10% adjudicated by the PEB.   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 pain condition.  

Chronic Low Back Pain.  According to STRs and the MEB NARSUM, the CI’s chronic low back pain condition began in March 2003 after a fall from a truck he was loading.  Physical therapy was instituted for right sacroiliac joint strain.  X-rays in July 2003 showed an “old L4 fracture.”  At the MEB examination, the CI reported lower back pain since he was injured in March 2003.  The examiner noted neuropathic pain of the sacroiliac joint to the right knee.  
On 6 October 2003 orthopedic examination revealed forward flexion of 80 degrees, extension 30 degrees, left and right flexion each 45 degrees and rotation left 40 degrees and right 50 degrees.  The diagnosis of chronic mechanical low back pain was made.  Physical therapy evaluation on 20 October 2003 revealed flexion 90 degrees and extension 25 degrees.  X-rays of the lumbosacral spine were normal except for a probable old fracture of the anterosuperior end-plate of L4 vertebral body.  Magnetic resonance imaging (MRI) of the lumbar spine in May 2004 demonstrated small Schmorl’s nodes (protrusion of disc soft tissue into the adjacent vertebrae) at the end plates of L2/L3 with minute focal disk bulging on the midline at L5/S1 interspace, which was felt not to be of clinical significance.  A small benign vertebral hemangioma of the L4 vertebral body was suspected.  

At the remote VA Compensation and Pension (C&P) examination in January 2007, performed 34 months after separation, the CI reported he fell or was pushed to get to a bunker area that resulted in back strain in March 2003, which progressed to low back pain on a chronic basis.  After separation the CI took Neurontin (gabapentin for nerve pain); however his low back pain increased and he had multiple flare-ups.  Physical examination revealed a normal gait and the capability of walking on toes and heels.  Trendelenburg’s sign (to determine weak or paralyzed abductor muscles of the hip) was absent as was straight leg raising bilaterally.  ROM measurements were flexion to 50 degrees, extension to 20 degrees, lateral bending to the right and left was each 30 degrees with some back pain and lateral torque (rotation) to the right and left was each 30 degrees.  The CI was able to do five repetitions with some back pain.  Muscle testing was normal and there were no dysesthesias of either foot.  X-rays of the lumbar spine were normal and the area of the spinous process in which the CI had noted a prior fracture appeared to be well healed without any defect in the area.  X-rays of the lumbosacral spine in January 2007 showed no acute or chronic radiographic abnormality.  A quite remote MRI with no probative value in June 2007, 39 months after separation, demonstrated a small central disc protrusion that abutted on both S1 nerve roots.  

The 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)	
Ortho ~5 Mos. Pre-Sep	PT ~5 Mos. Pre-Sep	VA C&P ~34 Mos. Post-Sep	
Flexion (90 Normal)	80	90	50	
Combined (240)		235	190	
§4.71a Rating	10%	PEB 0%	20% (VA 0%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5299-5237 code (lumbosacral strain), citing chronic low back pain, without neurological abnormality, forward flexion of 100 degrees.  The VA assigned a 0% rating using an analogous 5299-5237 code (leg, limitation of flexion) based on the VA C&P examination 34  month after separation, citing mechanical low back pain.  Board members discussed an orthopedic examination where flexion was 80 degrees which raised the possibility of a 10% rating; however, a subsequent examination 2 weeks later was otherwise normal but for an extension measurement of 25 degrees rather than 30 degrees.  Therefore, the Board was unable to find a route to a higher rating in the absence of painful motion, muscle spasm, guarding, or localized tenderness.

There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine and the MEB examination did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  The VA examination was too remote to have any significant probative value.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  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 was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

Contended PEB Conditions: Right Hip Tensor Fascia Lata Muscle Strain, Meralgia Paresthetica, and Benign Granulomatous Disease of the Lungs, Mediastinum and Spleen.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right hip tensor fascia lata muscle strain, meralgia paresthetica, and benign granulomatous disease of the lungs, mediastinum and spleen conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140421, 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 AR20160016225 (PD201401746)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA