RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01932
BRANCH OF SERVICE:  Army	BOARD DATE:  20141014
SEPARATION DATE:  20060820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SPC/E-4 (43M/Fabric Repair Specialist) medically separated for low back and left knee conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  The CI was permitted to take the alternate Army physical fitness test (aerobic portion).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The low back and left knee conditions, characterized as “chronic low back pain” and “patellofemoral pain/chondromalacia patella, left knee,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Hypertension and bunionectomy conditions were submitted by the MEB as medically acceptable.  The Informal PEB adjudicated “chronic low back pain (LBP) and chronic pain of the left knee” as unfitting, rated 10% and 0% respectively, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting low back and left knee conditions are addressed below; the hypertension and bunionectomy conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20060623	VA - (20 Mos. Pre-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Left Sacroilitis	5294	20%	20041216	
Chronic Pain of the Left Knee	5003	0%	Chronic Left Knee Bursitis	5019-5262	20%	20041216	
Hypertension	Not Unfitting	Hypertension	7101	NSC	20041216	
Bunionectomy	Not Unfitting	S/P Bunionectomy (R)	5010-5280	10%	20041216	
		S/P Bunionectomy (L)	5010-5280	10%	20041216	
Other x 0  (Not in Scope)	Other x 4 (Not in Scope)	20041216	
Combined:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20050126 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Low Back Pain Condition.  The record and narrative summary (NARSUM) indicated that the CI injured her back and left hip in January 2000 during martial arts training.  She underwent conservative therapy including an epidural injection which did not provide lasting relief.  The NARSUM noted that “Because of her knee and back problems, she was unable to attend advanced individual training for her military occupation specialty.  In September of 2001, she left the Active Guard Reserve program, and she has been in the individual ready reserve since then.”  In 2005 the pain from the “low back and sacroiliac joint areas” significantly interfered with duty requirements leading to the above noted profile and PEB.

At the VA Compensation and Pension (C&P) exam performed in 2002 (20 months prior to separation), the CI reported severe left buttocks area pain with spasms and the area was tender.  Exam documented a limp, requirement to stand during evaluation due to spasm while sitting, and hip flexion of 90 degrees (125 degrees normal).  The diagnoses were sacroiliac strain (where the lower spine joins the pelvis) and piriformis muscle syndrome (muscle in the buttock/hip area compressing the sciatic nerve – affects pelvis, hip and leg).  The VA rated this exam as 5294 (left sacroiliac) at 20% using the VASRD in effect at the time (prior to VASRD changes effective on 26 September 2003).

At the MEB exam, performed in 2005 (11 months prior to separation) the CI reported severe pain (7/10) in the low back and sacroiliac joint that interfered with sleep and limited walking, prolonged siting and wear of a rucksack.  She was taking non-narcotic medication three times a day and had no bowel or bladder symptoms.  The MEB physical exam noted a normal gait and spine/hip tenderness.  There was “near normal” pain-limited lumbosacral range-of-motion (ROM).  “She can bring her fingertips to her mid leg on forward flexion … (and had) more soreness leaning and rotating to the right.”  The ROMs charted below were stated as measured with an inclinometer (not a goniometer).  Lower extremity motor and sensory examinations were normal, and her pelvis was level.”  Hip ROM was 90 degrees pain-free for both hips.  Magnetic resonance imaging (MRI) from 2004 noted disc bulges, degenerative changes and narrowing of the nerve outlets (foramina).

The VA C&P exam performed in 2008, 25 months after separation, the CI reported lower back and left hip pain with flare-ups.  Exam documented an antalgic gait (limp), positive Gaenslen’s test (for sacroiliac joint pathology) on the left with pain limited left hip (120 degrees of 125 degrees) and lower spine ROMs.  Sensory, motor, and reflex exams were normal.  The goniometric 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.

Thoracolumbar ROM
(Degrees)	VA C&P ~20 Mo. Pre-Sep	MEB ~11 Mo. Pre-Sep	VA C&P ~25 Mo Post-Sep	
Flexion (90 Normal)	90	70*	60	
Combined (240)	215	200	165	
Comment	Painful motion; tender	Painful motion; *inclinometer used for ROM	Painful motion.  tender, painful hip ROM and + left Gaenslen test; (flex 65 before repetition)	
§4.71a Rating	10% (VA 20% -see text)	10%	20% (+ VA 10% L Piriformis)	

The Board directs attention to its rating recommendation based on the above evidence.  The VA’s 20% rating of the lower back was “non-schedular” and based on the old spine rules which were no longer in effect at the CI’s date of separation.  All pre-separation exams documented painful motion and IAW the VASRD in effect at the time would warrant a 10% rating under the general spine rating formula.  
The decreased ROM from the remote post-separation VA exam was considered to be post-separation worsening and not indicative of the CI’s disability level proximate to separation.  The spine formula includes symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine, as well as the sacroiliac joints as part of the thoracolumbar spine rating.  There was insufficient evidence of incapacitating episodes for any higher rating using the formula for rating intervertebral disc syndrome.

The Board considered there was no hip joint pathology documented and that the post-separation remote VA exam finding and rating for piriformis syndrome, coded as 8521 (External popliteal nerve common peroneal), rated at 10% for mild paralysis, represented post-separation worsening.  There was insufficient evidence of any weakness or non-pain radiculopathy for adjudging that any peripheral nerve condition was unfitting or ratable proximate to separation.  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 low back condition.

Chronic Pain of the Left Knee Condition.  The record documented initial left knee pain in 1997 following running with initial diagnosis of bursitis on imaging (MRI).  Knee pain increased with her back injury in 2000 and continued with intermittent pain and interference with running.  At the VA C&P exam, performed 20 months prior to separation, the CI reported intermittent left knee pain daily with occasional instability of giving way 1-2 times per month.  Exam of the knee documented severe tenderness and pain-limited ROM with no effusion or instability on testing.  Strength was 5/5 without evidence of muscle atrophy.  Imaging showed osteoarthritic changes.  At the MEB exam, performed 11 months prior to separation, the CI reported retropatellar crepitus and painful motion of 0-110 degrees (normal 0-140 degrees) with no objective signs of instability.  Gait was normal with no leg weakness and normal reflexes.  The VA C&P exam performed in 2008, 25 months after separation, the CI stated she felt something shifting in and out of her knee at times.  Exam documented a left antalgic gait with ROM of 0-100 degrees (normal 0-140 degrees).

The goniometric 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)	VA C&P ~20 Mo. Pre-Sep	MEB ~11 Mo. Pre-Sep	
VA C&P ~25 Mo Post-Sep	
Flexion (140 Normal)	90	110	100	
Extension (0 Normal)	0	-5	0	
Comment	Painful motion; hyperextension to 5; no instability	Passive ext to 0; tender to palpation	Antalgic gait; crepitus; 5-/5 strength; neg instability testing	
§4.71a Rating	10% (VA 20%)	10% (PEB 0%)	10% (VA 20%)	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the knee at 0% coded 5003 for arthritis of one joint, while the VA rated the knee at 20% coded 5019-5262 for bursitis with tibia and fibula moderate knee impairment on both pre- and post-separation VA exams.  No exams documented a compensable limitation of knee ROM under specific ROM-limitation diagnostic codes.  The Board considered the MEB exam was closest to the date of separation and had the highest probative value for rating.  However, given the entirety of the record, the Board adjudged that there was adequate reasonable doubt for painful motion (IAW VASRD §4.59) to warrant a 10% knee rating.  Absent any objective findings of instability or meniscal pathology, there was insufficient evidence for either dual rating of the knee or a 20% rating based on evidence proximate to separation.  
The Board considered the VARD knee rating of 20% and discussed VASRD §4.40 (functional loss) and rating under disability code 5262.  Board consensus was that the knee disability proximate to separation more nearly approximated the “slight knee disability” criteria for a 10% rating, versus the higher “moderate” 20% criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.59 (painful motion), the Board majority recommends a disability rating of 10% for the left knee condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Hypertension and Bunionectomy (feet) conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

The hypertension was well controlled on medication and the CI had a history of bunion surgery on each foot (1998 and 1999) with a good surgical outcome and retained hardware.  The only foot finding proximate to separation was foot tenderness.  The hypertension and bunionectomy conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  Although the L3 profile for the unfitting back and left knee conditions may have overshadowed any duty limitations attributable to the feet, there was no performance based evidence from the record that either the feet or hypertension conditions significantly interfered with satisfactory duty performance.  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 of the hypertension and bunionectomy conditions.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the lower back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee condition, the Board majority recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the contended hypertension and bunionectomy 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.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5237	10%	
Chronic Pain of the Left Knee	5003-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140430, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXXXXX, AR20150008222 (PD201401932)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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:

Encl			     XXXXXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA