RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01835
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20081125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Power Generator Equipment Repairer, medically separated for “bilateral patellofemoral syndrome,” rated 10% right knee and 10% left knee, with a combined disability rating of 20%.

CI CONTENTION:  The CI’s conditions continue to worsen and she now has a higher rating from the Veterans Administration.  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 - 20081106	VARD - 20090815	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Syndrome	5099-5003	10%	Bilateral Knee Patellofemoral Pain Syndrome also claimed as Bursitis 	5299-5260	0%	20090528	
		10%					
Low Back Pain	Not Unfitting 	Low Back Sprain	5237	NSC*	20090528	
Hyperventilation Syndrome	Not Unfitting	Traumatic Endolymphatic Hydrops…	6299-6204	10%	20090625	
Cognitive Disorder	Not Unfitting	Cognitive Disorder…	8045	40%	20090625	
Depression	Not Unfitting					
Uterine Neoplasm Benign-Leiomyoma	Not Unfitting	Uterine Neoplasm	7628	NSC	20090528	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 50%	
*VARD 20120626 increased to 10% for clear and unmistakable error

ANALYSIS SUMMARY:

Bilateral Patellofemoral Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain began in August 2007 after a motor vehicle accident in which she was rear-ended.

At an orthopedic visit in October 2007, 13 months pre-separation, the CI reported pain in the left knee joint and deep behind the kneecap, instability and locking.  The examiner documented full range of motion (ROM), with pain on patellar manipulation, but no evidence of effusion, instability, laxity, or meniscal injury.  Radiographic imaging in November 2007, 12 months pre-separation, documented a small posterior horn meniscal tear.  At the time of the orthopedic clinic appointment on 22 April 2008, 7 months pre-separation, the examiner recorded a normal gait, and full ROM in both knees, with bilateral crepitus.  There was no effusion or joint line tenderness.  There was no ligamentous laxity and meniscal signs were absent.  Strength and reflexes were normal, but reduced sensation on the sole of the left foot and left posterior leg was noted.

An MRI of the right knee on 28 April 2008 showed patellar cartilage abnormalities.  At an orthopedic visit in May 2008, 6 months pre-separation, the examiner diagnosed right “patellofemoral joint arthritis.”  At a visit with physical therapy (PT) in June 2005, 5 months pre-separation, the examiner documented right knee ROM from 0-110 degrees (normal 0-140) and left knee ROM from 0-118 degrees.  

An MRI of the left knee on 12 June 2008 also showed articular cartilage abnormalities and the previous medial meniscus findings were reclassified as “degeneration” rather than a tear.

At the time of the orthopedic appointment on 19 September 2008, 2 months pre-separation, the CI reported right peripatellar pain (8/10) and giving way 3 times per week.  On examination there was full ROM (painful motion was not addressed) and patellar grind (indicative of patellofemoral pain syndrome and chondromalacia).  There was no evidence of ligamentous laxity or meniscal injury.  There was no surgical indication, and conservative treatment to include PT did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral patellofemoral syndrome” for PEB adjudication.

A PT examination on 2 October 2008, 2 months pre-separation, revealed right knee extension to flexion from 0-115 degrees (normal 0-140) and left knee extension to flexion from 0-135 degrees (painful motion was not addressed) with no change after repetition.  At the MEB NARSUM examination on 23 October 2008, 1 month pre-separation, the examiner documented patellar laxity with crepitus and no evidence of instability.  The ROM measurements were noted to be consistent with the PT ROMs obtained on 2 October 2008.

At the VA Compensation and Pension (C&P) examination in May 2008, 6 months after separation, the CI reported constant 9/10 pain with weakness, giving way, lack of endurance, locking and difficulty standing, sitting, squatting, and running.  Physical examination showed a normal gait with no evidence of edema, weakness, tenderness, subluxation, guarding, locking, or crepitus.  Bilateral knee ROM was extension to flexion 0-130 degrees (painful motion was not addressed) with no additional limitations from pain, fatigue, weakness, lack of endurance or incoordination after repetition.  There was no evidence of ligamentous instability or meniscal pathology.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated each knee at 10%, analogously coded 5099-5003 code (degenerative arthritis), citing limitation of motion for one major joint applied to each joint.  The VA rated the bilateral knee condition at 0%, analogous coded 5299-5260 (leg, limitation of flexion) based on the VA C&P examination 6 months after separation, citing no objective evidence of arthritis with painful or limited motion.

The Board agreed there was no limitation of motion which supports a 10% rating for either knee under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was no documented painful motion to support functional loss IAW (§4.40, §4.59 and §4.45).  There was no evidence to support a rating for ligamentous laxity, locking or frequent effusions under codes 5257 or 5258.  Hence, there is no VASRD §4.71a route to a rating higher than 10% for either knee under any applicable knee code.  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 patellofemoral syndrome.

Contended PEB Conditions:  Low Back Pains, Hyperventilation Syndrome, Cognitive Disorder, Depression, and Uterine Neoplasm Benign-Leiomyoma.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting. 

Low Back Pain.  According to the STR and MEB NARSUM, the CI’s low back condition also began in August 2007 after a motor vehicle accident in which she was rear-ended.  An MRI revealed L5-S1 had mild hypertrophy of the right facet joint (intervertebral disc syndrome).  The CI was treated by PT and orthopedics with some improvement.  Therefore in May 2008 she attempted to pass the alternate physical fitness test (walk) but failed.  Her December 2007 permanent P3/L3 profile which listed low back pain and traumatic brain injury was updated to permanent L3 patella femoral pain syndrome both knees and chronic low back pain, dated June 2008.  This physical profile, 5 months before separation, restricted the CI from all physical fitness testing; no ruck, body armor or combatives; no lifting and carrying weight greater than 30 pounds, and no wearing of a protective mask and all chemical defense equipment.  Consequently, in addition to the CI’s knee condition, the CI’s low back condition could not be adequately treated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB in the May 2008 timeframe.  

The commander’s statement did not implicate any specific condition but recommended the CI for separation due to physical limitations of profile and stated the CI “cannot ruck, put on body armor or do combatives.”

During the MEB NARSUM on 23 October 2008, less than a month before separation, the physical examination revealed paralumbar tenderness but no spasm, guarding or Waddell’s signs.  The active thoracolumbar spine ROMs were full; painful motion was not addressed.  The examiner referenced the same MRI which demonstrated L5-S1 mild hypertrophy of the right facet joint in June 2008.  The examiner diagnosed low back pain (failed retention standards) which was forwarded for PEB adjudication.

At the VA C&P examination on 28 May 2009, 7 months after separation, the CI reported back pain that traveled down to her left knee and leg and restricted her ability to lift heavy weights, climb ladders, or stand and sit for prolonged periods.  Her back condition did not result in any incapacitations.  Physical examination revealed paralumbar tenderness, but no radiating pain on movement, no muscle spasm with a normal gait and posture.  The ROM were flexion 75 (normal 90) and combined ROM 225 (normal 240) ; painful motion was not addressed.

After due deliberation, the Board majority agreed that the preponderance of the evidence with regard to the functional impairment of the low back condition favors its recommendation as an additionally separately unfitting condition for disability rating.

The Board directed attention to the rating recommendation based on the above evidence.  The Board agreed both the MEB NARSUM and VA C&P examinations reported paraspinal tenderness which supports a 10% rating.  The STR and VA evidence was insufficient for limitation of motion to support a minimum 10% rating.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Additionally, the Board did not find evidence of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which significantly interfered with satisfactory duty performance at separation.

After due deliberation, considering the preponderance of the evidence, the Board majority recommends a disability rating of 10% for the low back pain, appropriately coded 5237 (lumbosacral strain) IAW VASRD §4.71a.

Hyperventilation Syndrome, Cognitive Disorder, Depression, and Uterine Neoplasm Benign-Leiomyoma.  None of these conditions were profiled or specifically implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that these contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for these contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bilateral patellofemoral syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended low back condition, the Board majority agrees that it was unfitting and recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended hyperventilation syndrome, cognitive disorder, depression and uterine neoplasm benign-leiomyoma 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 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	
Bilateral Patellofemoral Syndrome	5099-5003	20%	
Lumbosacral Strain	5237	10%	
COMBINED w/BLF	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140428, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB							
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 XXXXXXXXXX, AR20160011758 (PD201401835)

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 30% 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 30% 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
(  ) DVA