RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02129
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a activated National Guard, E4, Motor Transport Operator, medically separated for “degenerative disc disease” and “right knee pain…,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI additionally contends for consideration of his left knee in his application.  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 - Dated 20080923	VARD - 20090302	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disc Disease, Lumbar Spine	5242	10%	Status Post Lumbar Laminectomy with Degenerative Disc Disease at L5 - S1	5243	0%	20081106	
Right Knee Pain…	5099-5003	10%	Degenerative Joint Disease of the Right Knee, Status Post Surgery	5003-5260	0%	20081106	
Left Knee Osteoarthritis	Not Unfitting	Degenerative Arthritis of the Left Knee Joint	5003-5260	0%	20081106	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:  

Degenerative Disc Disease, Lumbar Spine.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in November 2006 after a fall while running and worsened in January 2007 after taking a physical training test.  At a physical therapy visit on 23 March 2007 the CI reported severe low back pain (LBP) that radiated to both lower extremities (LE’s), right greater than left.  Magnetic resonance imaging (MRI) on 31 March 2007 showed a large disc herniation at L2-3 which compromised the nerve root and the spinal canal.  At a neurosurgical consultation, a severe disc herniation was noted without evidence of neurologic compromise or myelopathy.  Surgery was performed in April 2007 at the L2-3 level.  Following the surgery the CI reported continued LBP that radiated to the bilateral LEs.  Repeat MRI studies on 30 May 2007 showed no evidence of recurrent herniation of the L2-3 disk, but increased disc herniation at L4-5 with significant spinal canal stenosis and disc herniation at L5-S1 with compromise of the right nerve roots.  The CI underwent repeat surgery in June 2007.  At a neurosurgery post-operative follow-up visit on 19 July 2007, the CI reported significant improvement since surgery with left lower extremity (LLE) symptoms resolved, but with occasional pain radiating to the right LE.  The CI had a change of duty station and lumbar spine X-rays on 4 December 2007 noted no degenerative arthritis.  There was no evidence of fracture or bony abnormality.  A request for MRI noted continued RLE symptoms and the MRI on 30 January 2008 showed moderate to severe degenerative disc disease (DDD) with bilateral neural foramen compromise at all levels.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 2 May 2007 (also noted to be for VA Compensation and Pension purposes), 8 months prior to separation, the CI reported constant LBP aggravated by activity and weather and relieved by medication and rest.  The physical examination showed normal gait without use of a cane or a crutch.  The lumbar spine was normal in appearance and there was no tenderness to palpation (TTP) or muscle spasm.  Thoracolumbar ROM was flexion of 70 degrees (normal 90 degrees) and combined ROM of 215 (normal 240 degrees).  There was no additional loss of ROM with repetition.  Lower extremity strength, sensation and reflexes were normal and straight leg raise testing (SLR- to elicit radicular symptoms) was positive on the right.  

The MEB NARSUM examination on 27 August 2008, 5 months prior to separation, noted complaints of LBP aggravated by activity.  Physical examination showed no swelling, TTP, muscle spasm, or guarding.  Gait and spinal contour were normal.  Physical therapy measured ROM for the MEB on 25 July 2008 was the same as noted at the MEB (DD Form 2808) examination with no TTP, muscle spasm, abnormal gait, or abnormal spinal contours noted.  

At the VA Compensation and Pension (C&P) examination on 6 November 2008, performed 2 months before separation, the CI reported constant back pain stiffness, numbness, and swelling of the lower back and tingling sensations in the lower back radiating to his feet.  The pain was aggravated by physical activity and relieved by taking medication (Tramadol and Gabapentin).  He reported he could function with medication and that the condition did not result in incapacitation or functional impairment.  On physical examination there was no TTP, muscle spasm or guarding.  Gait and spinal contours were normal.  There was no radiating pain with movement during the examination.  Thoracolumbar ROM after repetition was normal as recorded in the chart.  Lower extremity strength, sensation, and reflexes were normal and SLR was negative.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbar spine condition 10% coded 5242 (degenerative arthritis of the spine), citing limitation of motion.  The VA rated lumbar spine condition 0% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 2 months before separation, citing evidence of DDD.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 but not greater than 85 degrees) reported on the MEB DD Form 2808 and the MEB NARSUM.  There was no evidence at either of those examinations or the post-separation C&P examination of sufficient limitation of ROM or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour to support the 20% rating.  The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome.  Although the CI had intervertebral disc disease, following treatment, there were no incapacitating episodes requiring bed rest prescribed by a physician documented to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  Although the CI reported constant radiating LBP at the C&P examination 2 months after separation, he reported that he could function with medication and the condition had not resulted in incapacitation or functional impairment.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had a herniated disc with radicular pain treated with surgery and there were residual symptoms of radiating pain and tingling to the bilateral LEs documented in the treatment records; however, examinations indicated normal LE strength, sensation, and reflexes with normal unassisted gait.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  Radiating pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates)” and there is no evidence in this case that a motor or sensory deficit existed to any degree that could be described as functionally impairing.  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 degenerative disc disease, lumbar spine condition.

Right Knee Pain.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s right knee condition began in November 2006 when participating in a unit run, when fellow Soldiers stumbled falling on the CI.  Imaging studies 15 February 2007 showed cartilage defects involving the medial and lateral femoral trochlea, without evidence of a meniscal tear.  Surgery was performed in 27 August 2007 for repair of the cartilage defects.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right knee pain secondary to right knee repair” for PEB adjudication.

At the MEB examination the CI reported bilateral knee pain. .  The physical examination recorded for the bilateral knees showed full ROM without TTP.  There was no evidence of instability or meniscal pathology and LE strength, sensation and reflexes were normal.  At the MEB NARSUM examination the CI reported right knee pain, aggravated by activity and improved by ice, heat, relaxation, medication, and swimming.  The MEB physical examination noted surgical scarring present on the right knee.  There was no swelling or muscle atrophy.  The ROM was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal 0 degrees).

At the VA Compensation and Pension (C&P) examination on 6 November 2008, performed 2 months before separation, the CI reported constant pain in the knee joint that travels to his legs, with swelling and popping of both knees.  The pain was aggravated by physical activity and relieved by rest and medication.  Physical examination showed normal gait with full ROM after repetition.  There was no edema, effusion, weakness, tenderness, redness, crepitus, guarding of movement, locking pain, ligamentous instability or signs of meniscus (semi-lunar cartilage) pathology.

At a VA C&P examination on 1 August 2009, 7 months after separation, the CI reported right knee pain.  The physical examination showed mild swelling of the right knee.  The ROM was flexion of 120 degrees and extension of 0 degrees.  There was pain with maneuvers for meniscal pathology and medial and lateral joint line tenderness.  There was no crepitus.  Right knee X-rays showed “mild” osteoarthritis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% coded 5099-5003 (arthritis, degenerative [hypertrophic or osteoarthritis]), citing pain following surgery.  The VA rated the right knee condition 0% coded 5003-5260 (leg, limitation of flexion), citing X-ray evidence of degenerative joint disease of the right knee based on the post-separation C&P examination.  The VA additionally rated the right knee surgical scars at 0% under code 7804 (scars), asymptomatic.  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) or for limited motion of a single major joint coded according to 5003 criteria, as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  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 right knee pain condition.  

Contended PEB Conditions.  

Left knee osteoarthritis:  Notes in the service treatment records indicated that the CI reported left knee pain at an orthopedic visit 23 January 2008, 4 to 5 months after the initiation of the MEB.  Left knee MRI on 30 January 2008 showed chrondromalacia, medial meniscal degeneration, and two possible “tiny” loose bodies in the lateral aspect of the knee.  The orthopedic surgeon’s assessment was “mild” osteoarthritis (OA) of the left knee and no surgery was recommended at the time.  At the MEB examination the CI reported constant bilateral knee pain aggravated by activity and relieved by medication and rest, with normal examination of both knees as noted previously.  The physical examination recorded for the bilateral knees showed full ROM without TTP.  There was no evidence of instability or meniscal pathology and LE strength, sensation and reflexes were normal.  The MEB NARSUM noted left knee OA under “other conditions” and examination of the left knee showed ROM of flexion of 126 degrees and extension of 0 degrees (equal to the right) without swelling or muscle atrophy noted.  The diagnosis was “left knee osteoarthritis, medically acceptable.”  The permanent profile dated 5 April 2008 listed LBP due to DDD, “acute meniscal tear medial” and right knee pain.  The commander’s statement dated 29 April 2008 implicated the acute medial meniscus tear of the left knee and the CI’s DDD as impairing his duty performance.  The left knee OA condition was profiled and implicated in the commander’s statement, but was not judged to fail retention standards by the MEB NARSUM examiner and there was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance prior to referral into the MEB process.  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 left knee osteoarthritis condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the degenerative disc disease, lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee osteoarthritis condition, the Board unanimously recommends no change from the PEB determination 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 20140302, 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, AR20160008535 (PD201402129)

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