RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01893
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Military Police, medically separated for “chronic low back pain” and “chronic right knee pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contends right knee, back, PTSD, right ankle and left knee conditions.  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 – 20081204	VARD - 20090731	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Low Back Pain	5237	40%	20090323	
Chronic Right Knee Pain	5099-5003	10%	Right Knee Chondromalacia	5099-5014	10%	20090323	
Right [Bilateral] Ankle Instability and Pain	Not Unfitting	Right Ankle Instability	5271	10%	20090323	
Adjustment Disorder	Not Unfitting	PTSD	9411	30%	20090310	
Left Knee Pain and Popping	Not Unfitting	Left Knee DJD	5003	0%	20090323	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in January 2008 after lifting and carrying gear.  Magnetic resonance imaging (MRI) studies in February 2008, performed 12 months before separation, showed a posterior disc bulge at L4-L5 with likely annular fissure without canal stenosis or neuroforaminal narrowing and a central disc protrusion at L5-S1 with an annular fissure which may have contacted the bilateral traversing nerve root without canal stenosis or neuroforaminal narrowing.  

At the time of the physical therapy clinic appointment on 11 April 2008, performed 10 months before separation, the CI reported stabbing 4-9/10 low back pain (LBP) with lower extremity (LE) pain, numbness and tingling (N/T) without LE weakness (right LE weakness related to the knee) and no bladder or bowel dysfunction.  On examination there was increased lordosis in standing and slumped while sitting.  There was tenderness to palpitation (TTP).  Motor strength was normal and straight leg testing for radiculopathy was negative.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic non-radicular, 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)	NARSUM ~4 Mo. Pre-Sep	VA ~2 Mo. Post-Sep	
Flexion (90 Normal)	75	20	
Combined (240)	>190 <205	120	
Comments	Painful motion; flares (see text)	Painful motion; tenderness; guarding with normal gait	
§4.71a Rating	10%-40%	40%	

At the MEB examination (recorded on an addendum to the DD Form 2808) dated 29 July 2008, 6 months prior to separation, an examination of the spine demonstrated TTP over the bilateral and posterior superior iliac spine.  Straight leg testing for radiculopathy was negative.  Motor strength was normal; deep tendon reflexes were 2+/4 and symmetrical (normal).  On sensory testing the CI described “some vague numbness and tingling with poorly defined boarders on the anterior, lateral thigh regions that roughly outlined the femoral cutaneous nerves.”  ROM was described as forward flexion with fingertips to the floor without added pain and normal painless hyperextension, twisting and side bending.  There was moderate pain with Gaenslen’s maneuver testing for sacroiliac joint (SIJ) dysfunction with a described snapping sensation in the lower back, and pain on Patrick’s test for SIJ or hip dysfunction.  Tinel’s signs for nerve irritation were positive over the bilateral, lateral femoral cutaneous nerves.  

At the MEB NARSUM examination on 2 October 2008, performed 4 months prior to separation, the CI complained of back pain with numbness and tingling down the right leg not relieved by chiropractic therapy and massage.  She had an epidural steroid injection 8 days earlier which increased the pain, and she had a flare of her back pain with 3 days of quarters.  Anti-inflammatory medications were not effective, and she was started on narcotic pain medication.  Back pain frequently awakened her from sleep and she had flares of pain reaching 8-9/10.  “It is speculated that she loses 70% to 100% of her range of motion during such a flare secondary to pain, but not other factors such as fatigue, weakness, lack of endurance, instability or incoordination.  At these times, her pain is so severe that it is difficult to rise from a chair.  Flares can last for days at a time, and eventually resolve with rest.”  The back condition was assessed as worsening with “approximately 60% worse than when it began in January 2008.  … significantly less tolerance for standing or sitting in one position than she did a few months ago.”  

The examiner cited the October 2008 PEB examination (above), and recorded the thoracolumbar ROM of forward flexion of greater than 70 degrees but not greater than 80 degrees (90 degrees normal) limited by pain, with a combined ROM of greater than 190 degrees but not greater than 205 degrees (240 degrees normal).  Pain was 5/10 at the beginning and end of ROM.  
At the VA Compensation and Pension (C&P) examination on 23 March 2009, performed 2 months after separation, the physical examination showed TTP of the bilateral posterior superior iliac spine with a mild tingling sensation.  There were no spasms and gait was normal.  Muscle strength was 5/5 bilaterally, deep tendon reflexes were 2+ and sensation to the LE was intact except for decreased sensation along the lateral aspect of the right foot.  Straight leg raise testing was 90 degrees (normal) on the left and 55 degrees on the right which the CI reported was likely due to knee pain.  The ROM of the lumbosacral spine was forward flexion of 20 degrees (90 degrees normal) with a combined ROM of 120 degrees; pain increased with each repetition; however, there was no weakness fatigue or lack of endurance.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10% coded analogous to 5237 (lumbosacral strain), citing forward flexion of 71-80 degrees, limited by pain.  The VA rated the low back pain condition 40% coded 5237 (lumbosacral strain), based on the VA C&P examination 2 months after separation, citing limitation of forward flexion.  

In assigning probative value to these somewhat conflicting examinations, the Board noted that a review of the STR did not detail any further injury or worsening of the condition prior to separation, and the MEB ROM measurements were consistent with the diagnostic and clinical pathology in evidence, consistent observations of normal gait without muscle spasm or muscle weakness.  The speculation of decreased functioning with flares was noted, but not confirmed by any pre-separation evidence.  The VA examination’s more severely limited ROMs were adjudged as an outlier to the preponderance of the record, and not representative of the CI’s disability picture at the time of separation.  The Board adjudged that the NARSUM examination had the highest probative value for rating at separation.  

The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined range of motion (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM examination.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain 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 was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

Chronic Right Knee Pain associated with Chondromalacia and Plica.  According to STRs and the MEB NARSUM, the CI underwent right knee surgery in May 2008 to investigate a possible tear in the posterior cruciate ligament (PCL).  The PCL was intact; however, the arthroscopic surgery revealed a mild chondromalacia patella, and bone fragments were removed.  Surgery and further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right knee pain with mild chondromalacia” 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)	DD 2808 ~ 6 Mo. Pre-Sep	NARSUM ~ 4 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	VA Ortho ~9 Mo. Post-Sep	
Flexion (140 Normal)	115	129, 126, 125	110	140	
Extension (0 Normal)	+4	-4, -3, -3	0	-5	
Comment:  Surgery ~9 Mo. Pre-Sep	Tenderness; Pain on squat	Pain with motion; soft tissue limitation	Painful motion/tenderness	Tenderness	
§4.71a Rating	10%	10%	10%	10%	

At the MEB examination, the physical examination showed the CI was “very” tender at the medial portion of the patella, which increased when the knee was flexed 90 degrees.  There was mild pain in the medial compartment on the McMurray test (for meniscal symptoms) and on the Apley test (patellar grind).  There was no ligamentous laxity or instability.  The ROM was flexion of 115 degrees (140 degrees normal) and extension of plus 4 degrees (0 degrees normal).  

At the MEB NARSUM, the history indicated the ankle condition was long standing.  Examination recorded painful ROM as charted above.  X-ray studies on 27 December 2008, performed 1 month before separation, showed no radiographically evident bony abnormalities.  

At the VA C&P evaluation the physical examination showed TTP of the inferior to right patella.  There was no “obvious” laxity and gait was normal.  McMurray, drawer, varus and valgus testing was negative (no laxity or instability).  The ROM is charted above, with no additional limitations due to weakness, fatigue or lack of endurance on repetition.  

At the time of the VA orthopedic surgery clinic appointment on 19 October 2009, performed 9 months after separation the CI reported no improvement in her right knee since surgery in 2008.  On examination there was no effusion, the knee was stable to stress and Lachman’s testing was negative.  There was medial joint line tenderness and a positive McMurray test.  X-ray studies referenced in this examination showed early degenerative joint disease with possible medial meniscal tear, with ROM as charted above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded analogous to 5003 (arthritis, degenerative), citing limitation of motion due to pain.  The VA rated the right knee condition 10%, coded analogous to 5014 (osteomalacia), citing painful or limited motion joint or group of minor joints based on the C&P examination, 2 months post-separation.  

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).  There was no history of dislocated meniscus or loose body (following surgery) causing frequent locking with recurrent effusions (5258).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was potentially applicable in this case, but the maximum 10% rating under that code provided no benefit to the CI.  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 chronic right knee pain associated with chondromalacia and plica condition.  
Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the adjustment disorder, left knee, and right ankle instability conditions were not unfitting.  

Adjustment Disorder.  The adjustment disorder is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending it as unfitting.  

Left knee:  The left knee condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards by the MEB.  There was no performance based evidence from the record that the left knee condition significantly interfered with satisfactory duty performance.  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 the contended left knee condition and so no additional disability rating is recommended.  

Right Ankle Instability and Pain. Only the right ankle was contended and is in scope although he MEB forwarded “bilateral ankle instability and pain.”  The right ankle condition was profiled (bilateral ankle instability and pain), alternate foot gear was authorized, and the ankle condition was judged to fail retention standards by the MEB.  The commander’s statement did not specify any individual medical condition, but stated the CI did not perform as the main focus was to attend medical appointments.  The right ankle condition was reviewed and considered by the Board.  According to STRs and the MEB NARSUM, the CI’s right ankle condition began in 2002 with frequent right ankle sprains, which increased in pain and frequency and the CI was issued arch supports.  Diagnostic imaging in September 2008 documented a complete tear of the anterior talofibular ligament (outside of ankle) with a thickened, but intact, calcaneofibular ligament.  The NARSUM indicated that the CI’s “chrome ankle pain and instability have finally reached the point where they prohibit the effective performance of her military duties.”  Ankle pain was exacerbated by prolonged walking, standing, walking on uneven terrain, or shoe wear.  Ankle braces did not help.  She had flares with a speculated 50% loss of motion with pain up to 7/10 and swelling.  Diagnostic imaging in September 2008 showing a complete tear of the anterior talofibular ligament (outside of ankle) with a thickened, but intact, calcaneofibular ligament.  Examinations in evidence documented normal, or near normal ROM of the ankle with tenderness, laxity and instability without any abnormal gait noted.  The record indicated that the CI had not required ankle physical therapy, and there were few treatment notes for the right ankle condition.  The CI was engaged in softball and the March 2008 DD Form 2697 (Report of Medical Assessment) did not mention the ankle condition.  

The Board directed attention to its fitness and rating recommendation based on the above evidence.  The CI’s ankle instability and pain was longstanding and diagnostic imaging revealed chronic changes not consistent with an acute injury.  The Board considered if there was a preponderance of evidence that the ankle condition was unfitting and the provisions of DoDI 1332.38, E3.P3.3.3. (Adequate Performance Until Referral).  

There was not a preponderance of performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  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 instability, right ankle contended condition and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right ankle, left knee, adjustment disorder 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 20140304, 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 XXXXXXXXXXXXXXXXXXXXXXX AR2016001 0655 (PD201401893)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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