RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX                	CASE:  PD-2014-02045
BRANCH OF SERVICE:  Army          	SEPARATION DATE:  20060316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated for “chronic low back pain” and “right knee pain,” rated 0% and 0%, respectively, with a combined disability rating of 0%.  

CI CONTENTION:  The applicant states that the VA rated additional related 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 - 20060130	VARD - 20070202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	0%	Compression Fracture, Thoracic Spine	5235	10%	20060303
20061129	
Chronic Right Knee Pain…	5099-5003	0%	Postoperative Patellofemoral Syndrome, Right Knee	5257-5260	10%	20060303
20061129	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain began in 1998 secondary to a motor vehicle accident (MVA) and was worsened by a second MVA in January 2004.  He was diagnosed with possible mild compression fractures of T7 and T8, but there were conflicting imaging reports as to whether or not there were fractures and, if so, whether they were congenital.  There were no radicular symptoms and there was ample STR documentation of normal neurological findings.  Magnetic resonance imaging (MRI) demonstrated mild degenerative changes without disc disease, and reported otherwise normal vertebral bodies.  There was STR documentation of a normal gait, and no indication of gait disturbance due to spine disease.  Mild kyphosis (abnormal forward bowing of the spine) was documented by an orthopedic consultant, who opined that this was congenital rather than traumatic.  There was no correlation of spasm or guarding with the spinal contour abnormality, and no STR documentation of incapacitating episodes.  There were some STR entries noting normal range of motion (ROM) and others noting non-specifically decreased ROM with painful motion, but none indicating severe limitation.  Measured ROM by physical therapy was average flexion of 75 degrees (normal 90), average extension of 20 degrees (normal 30), normal bilateral rotation, and no measurement of lateral flexion for calculation of combined ROM.  

Despite treatment, the condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, and the CI was referred for an MEB.  The MEB forwarded “healed T7 compression fracture with mild kyphotic deformity” for PEB adjudication.  

The MEB NARSUM examination on 5 December 2005 (3 months prior to separation) did not characterize the pain or elaborate functional limitations.  The physical examination recorded a “slight” antalgic gait attributed to the right knee, “a mild kyphotic deformity” without note of spasm or guarding, “mild” tenderness over the mid-thoracic spine, and normal neurological findings (motor, sensory, and reflexes).  The examiner documented two positive Waddel’s signs (indicators of unreliable findings) without elaboration, and did not comment on ROM.

The 3 March 2006 VA Compensation and Pension (C&P) evaluation, performed 2 weeks before separation, documented “intermittent ... severe” pain without extremity radiation, aggravated by heavy lifting, bending, and prolonged sitting.  The physical examination recorded gait as “pretty close to normal,” localized tenderness over T7, a “straight” spine, the absence of spasm, and normal neurological findings.  The ROM measurements were flexion of 70 degrees and combined ROM of 220 degrees (normal 240), noting pain but no ROM degradation with repetitions.

The 29 November 2006 VA Orthopedic C&P evaluation 8 months after separation,  documented “persistent” thoracic pain without radicular pain and noted that the CI was “able to do his normal job ... [and] ... normal activities.”  The physical examination recorded a normal spinal contour (no comment regarding gait), tenderness, “some muscle spasms,” and normal neurological findings.  The ROM measurements were flexion of 80 degrees and combined ROM of 200 degrees, specifying painful motion.  The 16 November 2006 VA C&P evaluation, 2 weeks earlier, documented employment doing truck body repair (similar to MOS) and a normal gait.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated “chronic low back pain” 0%, coded 5237 (lumbosacral strain), citing “2/5 Waddell signs.”  The VA also rated “chronic low back pain” 10%, coded 5235 (vertebral fracture or dislocation), citing the ROM evidence from the post-separation orthopedic C&P examination.  All of the ROM evidence in this case is consistent with VASRD §4.71a criteria for a 10% rating, in addition to ample documentation of painful motion.  There was insufficient evidence of abnormal gait due to spine disease or abnormal spinal contour correlated with muscle spasm or guarding to support either of those 20% criteria.  There was no diagnosis of intervertebral disc disease or documentation of incapacitating episodes to support a higher rating under that formula, and there was no associated neuropathy for consideration of additional rating on that basis.    

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic low back condition, coded 5242 (degenerative arthritis of the spine).
Chronic Right Knee Pain.  The CI injured his knee while negotiating an obstacle course in 2000, reporting a dislocated patella manually reduced on the scene.  An MRI demonstrated chondromalacia patella (damage to the cartilage under the knee cap) with normal menisci and ligaments.  An arthroscopic lateral release (to stabilize the patella) was performed on 20 October 2003 (2½ years before separation).  There was STR documentation of joint stability to stress testing, the absence of effusion, and the absence of signs of impingement (locking); with no entries to the contrary.  There was STR documentation of flexion from 110 degrees (normal 140) to grossly normal and normal extension (0 degrees).  

Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right knee pain” for PEB adjudication.  

The MEB NARSUM examination on 5 December 2005 (3 months prior to separation) documented persistent “retropatellar” pain (no comment regarding subjective instability or locking) aggravated by prolonged sitting, negotiating stairs, and heavy lifting and prohibiting running or ruck marching.  The physical examination recorded the slight gait disturbance noted above, pain with patellar compression, and joint stability to stress testing in all planes.  The ROM measurements were normal (flexion 140, extension 0).  Formal ROM measurements by Physical Therapy (PT) on 12 January 2006 (2 months prior to separation) were average flexion to 115 degrees and average extension of minus 10 degrees (the 10% rating threshold).  The latter was the only documentation in the Service or VA files for abnormal extension.  

The 3 March 2006 VA Compensation and Pension (C&P) evaluation, performed 2 weeks before separation, documented constant pain with similar functional limitations to those in the NARSUM, but noted “giving out” on occasion and the “sometimes” use of a brace.  The physical examination recorded a normal gait (as above), the absence of effusion or tenderness, a suggestion of patellar laxity with full extension, and joint stability to stress testing.  The ROM measurements were flexion to 125 degrees and extension 0 degrees, specifying painful motion.      

The 29 November 2006 VA Orthopedic C&P evaluation 8 months after separation documented “persistent pain ... occasionally limps” and use of a brace, but noted the absence of significant occupational limitations.  The physical examination recorded “retropatellar pain ... [and] ... crepitation” with no note of effusion or instability.  The ROM measurements were flexion to 135 degrees and extension 0 degrees, noting pain with repetition.    

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated “chronic right knee pain” 0%, coded analogous to 5003 (arthritis, degenerative).  The VA rated “chronic right knee pain” 10%, coded 5257-5260 (knee, other impairment rated for limitation of flexion), citing “pain on use.”  There was no ROM limitation in evidence meeting the minimum 10% threshold, except for the isolated PT measurement of extension (as above), which members agreed was insufficiently probative (contrary to all other evidence) as the sole basis for the Board’s recommendation; however, members did agree that either VASRD §4.59 (painful motion) or §4.40 (functional loss) was reasonably conceded in support of the minimum 10% rating.  Members further agreed that, although the CI used a brace (most likely for patellar stabilization) and intermittently complained of subjective instability, there was no objective evidence for joint instability with MRI confirmation of intact ligaments; thus, additional rating for instability was not justified.  There was no persistent effusion and locking, or fracture with non-union or malunion to achieve a rating higher than 10% under any alternate code.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee condition, coded 5099-5024 (tenosynovitis).  

BOARD FINDINGS:  In the matter of the “chronic low back pain” condition, the Board unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the “chronic right knee pain” condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 IAW VASRD §4.71a.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5242	10%	
Chronic Right Knee Pain	5099-5024	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140508, 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 AR2016001 0885 (PD201402045)

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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA