RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02002
BRANCH OF SERVICE:  Army	BOARD DATE:  20150623
SEPARATION DATE:  20080211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Healthcare Specialist) medically separated for low back and right knee conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U2L3 profile and referred for a Medical Evaluation Board (MEB).  The “low back pain, myofascial, non-radicular, secondary to joint hypertrophy” and “post-surgical knee pain secondary to traumatic osteoarthritis and retained hardware” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (bilateral shoulder pain) meeting retention standards for PEB adjudication.  The initial Informal PEB convened on 23 October 2007 and adjudicated “chronic low back pain” and “right knee injury” as unfitting, rated 10% and 0% respectively with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition (bilateral shoulder pain) was determined to be not unfitting.  The CI was then separated on 11 February 2008.  The records available do not provide information about why, but an Administrative PEB dated 25 February 2009 adjudicated his conditions as “lumbar sponydlosis (arthritis) degenerative disc disease” and “posttraumatic arthritis of right knee with lateral collateral ligament reconstruction and proximal tibial wedge osteomy” as unfitting and rated 10% and 10% respectively, resulting in an increased combined disability rating of 20%.

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 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/Naval 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 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:

Admin IPEB – Dated 20090225	VA* - (~2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Spondylosis …	5242	10%	Degenerative Disc Disease Lumbar Spine	5242	10%	20071127	
Posttraumatic Arthritis of the Right Knee …  	5010	10%	Residuals, S/P Lateral Collateral Ligament Reconstruction Right Knee	5299-5260	10%	20071127	
Bilateral Shoulder Pain	Not unfitting	Bilateral Shoulder Pain	5201	NSC	20071127	
Other x 0 (Not In Scope)	Other x 1	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080417 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  

Lumbar Spondylosis Condition.  The narrative summary (NARSUM) detailed that the CI had the onset of low back pain during a deployment to Iraq.  Upon his return, he was diagnosed with lumbar spondylosis (degenerative disease) and intervertebral disc degeneration.  He was treated with physical therapy, a home exercise program, and the first of three planned nerve ablation paravertebral facet joint injections.  The first injection to his back provided almost complete relief for 3 days, but pain returned to the previous level after resumption of his usual activities.

X-rays of the lumbar spine in May 2007 were normal.  Magnetic resonance imaging (MRI) showed disc degeneration at L1-2 and L4-5, and a disc bulge at L4-5 “causing at least moderate left neural foraminal narrowing” (with potential pressure on the associated nerve).  At a neurosurgery appointment on 29 August 2007 (6 months prior to separation), the lumbosacral spine had normal appearance and lumbosacral spine motion was “normal,” although there was painful motion with flexion.  There was tenderness at the L4-5 level at the midline and of the bilateral paraspinal musculature, but no muscle spasm.  Muscle strength and sensation were normal, while gait was abnormal:  “Limping is observed.  Heel walking was normal.  Toe walking was normal.”

At a physical medicine appointment a week later (5 September), gait and stance were normal, there was back muscle tenderness but no muscle spasms, sensation was normal, and there was no lower extremity weakness.  A physical therapy evaluation (same day) showed forward flexion 80 degrees, combined range-of-motion (ROM) 200 degrees, painful motion, no muscle spasm or guarding, normal gait, and a decrease in lumbar lordosis.  At another physical medicine appointment a week after that, the CI was observed to ambulate “from the exam room to the fluoro suite and transfer onto the procedure table independently and without difficulty.”  On examination, there were no focal neurological deficits.

The DD Form 2808, Report of Medical Examination, was completed on 17 September 2007, 5 months prior to separation, and was referenced in the NARSUM.  The CI had “FAROM” [full active ROM] of the spine, pain on standing fully erect after full flexion, and moderate paraspinal muscle spasms.

A VA Pre-Discharge Examination that was conducted on 27 November 2007 (3 months prior to separation) was synopsized in the VARD.  This examination detailed no tenderness, and normal gait and posture.  The report noted that “range of motion was within normal limits except for a decrease of 10 degrees on lumbar extension,” and additional limitation of joint function due to pain after repetitive use.

At a physical therapy evaluation on 6 November 2008 (9 months after separation and 2 months post right knee hardware removal), the CI complained of right leg heaviness, knee pain, and pain with heel strike.  The examiner noted full weight-bearing but antalgic gait on the right, right thigh atrophy, mild decrease in hip flexion during the swing phase, tenderness of the patella, full ROM of the knees, and normal strength of both legs.  The examiner stated that the CI presented with “primary problems of R hip weakness, R quad[riceps] atrophy …, R patella laterally tracking, pain/discomfort with ambulation and stair negotiation.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10%, coded 5242 (degenerative arthritis of the spine), citing the decreased ROM, and normal gait and stance.  The VA also rated the condition at 10%, coded 5242, citing painful motion.  Abnormal spinal contour (“decreased lumbar lordosis”) and limping was described in some (but not all) exams, but was not found to be secondary to muscles spasm or guarding, so a rating of 20% was not supported (“muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis”).  There was not a pathway to a higher rating based on ankylosis, ROM, or periods of bed rest prescribed by a physician.  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 lumbar spondylosis condition.

Post-traumatic Arthritis of the Right Knee.  The service treatment record (STR) detailed that the CI had a varus force (from the inside or medial aspect) to the right knee while wrestling (combat training), with immediate swelling, in November 2003 (4 years prior to separation).  He was evaluated and felt to have damage to the lateral collateral ligament (LCL) and the posterior cruciate ligament (PCL).  He was referred for physical therapy with improvement in his symptoms, but noted increased pain and instability during a subsequent deployment.  An examination in April 2005 demonstrated posterior sag, lateral laxity with good endpoint (suggestive of PCL injury), and slight pivot (suggestive of injury to the anterior cruciate ligament [ACL]).  In August 2006 (18 months prior to separation) the CI had reconstructive surgery of the LCL with proximal tibia opening wedge osteotomy (realignment of the large bone in the lower leg).  The ACL and PCL were visualized during the surgery and appeared intact, except some partial fiber damage of the ACL.  The CI had another surgery a month later with debridement due to infection.  He continued to have pain and dysfunction that interfered with his military duties, and was referred for an MEB.

At an orthopedic follow-up on 18 May 2007 (7 months after surgery and 9 months prior to separation), the surgeon stated, “no functional instability whatsoever in spite of mild residual laxity on exam.”  An orthopedic evaluation on 6 August 2007 (6 months prior to separation), showed well-healed surgical scars, ROM from 0 to 130 degrees (normal 0 to 140), mild medial joint line tenderness, and negative McMurray sign.  Lachman test revealed Grade 1 laxity with good endpoint and negative pivot shift (suggesting mild laxity of the ACL); the posterior drawer test was Grade 1 with the tibial plateau just anterior to the condyles (suggesting mild laxity of the PCL); while the knee was stable full extension but had 5-8 degrees of opening with varus in 30 degrees of flexion.  A physical therapy evaluation on 5 September 2007 showed ROM from -1 (hyperextension) to 133, no pain with ROM, and a 2+ Lachman test (versus 1+ on the left).

The DD Form 2808 dated 17 September 2007 (5 months prior to separation) documented well-healed surgical scars, bony enlargement of the medial tibial plateau, no instability, and tenderness of the patellar tendon.

The VA Pre-Discharge Examination exam on 27 November 2007, 3 months prior to separation (referenced in the VARD), revealed ROM 0 to 135 degrees with pain, with additional limitation joint function due to pain after repetitive use.  The collateral ligament stability and meniscus were normal but, there was moderate laxity of the ACL.  X-rays of the knee were normal.

At a VA orthopedic evaluation on 16 June 2008 (4 months after separation), the CI continued to experience pain and tenderness and clicking of the right knee, but no swelling.  On examination there were two surgical scars, tender palpable screw heads on the medial tibia, some laxity of the medial collateral ligament, and ROM from 0 to 130 degrees.  X-rays showed normal position and alignment of the knee joint with corrected genu varum deformity and no evidence of osteoarthritis of the knee.  At a VA orthopedic evaluation in October 2008 (8 months after separation and 3 months after right knee hardware removal), there was no instability of the knee.

The Board directed attention to its rating recommendation based on the above evidence.  The Administrative PEB rated the condition under code 5010 (Arthritis, due to trauma) at 10%, citing functional loss.  The VARD rated the condition analogously under code 5260 (limitation of flexion of leg) at 10%, citing painful limited motion.  Although some post-surgical exams reported laxity of various ligaments in the knee, this was not associated with symptomatic recurrent subluxation or lateral instability and, thus, did not support a higher rating.  There was not a pathway to a higher rating based on ankylosis, ROM, frequent episodes of “locking pain” and effusion into the joint associated with semilunar cartilage injury, or nonunion or malunion of the tibia and fibula.  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 right knee condition.

Contended PEB Condition.  The Board acknowledges the CI’s implied contention for service ratings of his bilateral shoulder condition, which was determined to be not unfitting by the PEB.  The Board’s main charge with respect to this condition is an assessment of the fairness of the PEB’s determinations that it was they were not unfitting.  The Board’s threshold for countering service fitness determinations is preponderance of evidence, which 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 STR detailed that the CI’s bilateral shoulder pain started “downrange after long periods of wearing IBA [individual body armor].”  At a physical evaluation in September 2005 (DD Form 2807-1, Report of Medical History), almost 3 years prior to separation, the CI complained of right shoulder pain but it was not further delineated.  The accompanying examination demonstrated tenderness to palpation, crepitus, and decreased internal rotation.  X-rays showed degenerative changes in the right acromioclavicular (collarbone) joint.  In a follow-up telephone contact a week later, the CI requested a profile for shoulder pain with parade rest and push-ups.  The CI was given a temporary U-2 profile and was referred for physical therapy.

He was seen in primary care in February 2006 for bilateral shoulder pain and clicking in the right shoulder.  On examination there was tenderness, decreased ROM, painful motion throughout the ROM, and weakness on internal rotation of both shoulders.  At his physical fitness test on 6 June 2006, the CI did 80 push-ups.  An MRI of the left shoulder in June 2007 was normal.

The DD Form 2808 documented decreased internal rotation but otherwise full active ROM of the shoulders, tenderness to palpation, and pain with resisted flexion.

In the NARSUM, accomplished on the same day, the CI described pain that was constant but varied depending on activity (severity 1-5/10), and was exacerbated by carrying weight, reaching overhead, internal rotation, parade rest, and push-ups.  The examiner stated that the pain did not keep the CI from his MOS duties or from general military duties (except prolonged wear of the IBA or any attempt at the 3-5 second rushes), although he couldn’t do push-ups, overhead work, side straddle hops, or stand for prolonged periods at parade rest.  The pain did not interfere with sleep, and did not interfere with activities of daily living.  The examiner concluded that the shoulder condition met retention standards.

In a letter of evaluation, the commander stated that the CI was unable to perform his duties due to functional activity limitations of the shoulder (U-3) and knee (L-3) from a previous DA Form 3349, Physical Profile.  A subsequent DA Form 3349 on 17 September 2007 updated the U-3 profile facet to a U-2.

At the VA examination in November 2007 (3 months prior to separation), as referenced in the VARD, the CI stated that he had bilateral shoulder pain since 2004, left greater than right.  The pain was occasional, was related to increased activity, and was relieved by over-the-counter pain relief medication or physical therapy.  Examination of the shoulders was within normal limits with no redness, swelling, or tenderness.  ROM was normal; there was slight pain at flexion, and no additional limitation after repetitive use.

At a VA Iraq/Afghan registry evaluation on 8 May 2008 (3 months after separation), the CI complained of bilateral shoulder pain since 2004, left worse than right, which was worse with heavy lifting.  On examination, there was, “No swelling or erythema of joints.”

The Board directed attention to its recommendation based on the above evidence.  The commander expressed concern about the profile associated with the shoulder condition, but the profile was subsequently modified from U-3 to U2, which is acceptable for the CI’s MOS.  The NARSUM and the MEB stated that the bilateral shoulder condition met retention standards.  After review of these issues, there was no performance based evidence from the record that the bilateral shoulder condition significantly interfered with satisfactory duty performance.  After due deliberation 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 bilateral shoulder condition; thus no additional disability ratings can be recommended.

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 lumbar spondylosis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the post-traumatic arthritis of the right knee and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral shoulder 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, 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 20140502, 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 XXXXXXXXXXXXXXXXXXXX, AR20150018386 (PD201402002)

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