RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-02145
BRANCH OF SERVICE:  army	BOARD DATE:  20140912
SEPARATION DATE:  20090524

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (11B2O/Infantryman) medically separated for a pain syndrome and right knee condition.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forward chronic right knee pain and complex regional pain syndrome, right knee conditions, characterized as medically unacceptable, to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions to the PEB.  The Informal PEB adjudicated complex regional pain syndrome with chronic right knee pain as unfitting, rated at 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  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 rating for the unfitting complex regional pain syndrome with complex right knee pain conditions are addressed below.  The ratings for the unfitting hearing, shoulder, back and dermatitis conditions, as per the contention, will also be addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20090220	VA1 - (.6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complex Regional Pain… Chronic Right Knee pain	8699-8620	20%	Right Knee Strain…	5020	0%	200906122	
Mid-Frequency Bilateral Hearing Loss	Not Unfitting	Hearing Loss, Left Ear	6100	0%	200906122	
		Hearing Loss, Right Ear	6100	NSC	200906122	
History of Shoulder Pain	Not Unfitting	Left Shoulder Condition	5201	NSC	20081021	
		Right Shoulder Strain	5201	NSC	20081021	
History of Low Back Pain	Not Unfitting	Lumbar Degeneration…	5242	0%	200906122	
Dermatitis on Hand	Not Unfitting	Skin Condition, Bilateral Hands	7806	NSC	200906122	
Other x 0 (Not in Scope)	Other x 2 (Not in Scope)	200906122	
Combined:  20%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20090727 (most proximate to date of separation)
C&P 20090612 missing from evidence, Board referenced the exam’s findings in VARD 20090727

ANALYSIS SUMMARY:

Complex Regional Pain Syndrome with Chronic Right Knee Pain.  The MEB examiner noted the CI’s history of chronic right knee pain began during a 12-mile road march in April 2007.  His knee pain was treated conservatively with medications and physical therapy (PT); however, his pain persisted.  Magnetic resonance imaging (MRI) of the right knee in November 2007 demonstrated mild chondromalacia patella.  Posterior cruciate ligament tear could not be ruled out.  The MEB examiner noted that the CI underwent orthopedic surgery (chondroplasty) in April 2008 for a possible lateral meniscal tear of the right knee.  The surgery was noted to have been successful; however, the CI had increased pain postoperative.  The range-of-motion (ROM) recorded post-surgery indicated knee flexion to 95 degrees.  The CI continued with his regular physical therapy sessions.

The 21 May 2008 orthopedic examination recorded right knee flexion of 120 degrees and flexion of 130 was noted at the June 2008 exam.  A physician opined dated 13 August 2008 that the CI possibly had some form of complex regional pain syndrome and discussed having another diagnostic MRI for further evaluation.  The CI requested a second opinion and was referred to another orthopedic physician.

A second orthopedic examination dated 10 September 2008 recorded the diagnosis of reflex sympathetic dystrophy and noted that was the appropriate diagnosis since both a MRI and arthroscopic findings were negative.  ROM evaluation of the right knee recorded flexion of 135 degrees, without evidence of effusion, crepitance and knee instability.  The post-operative MRI of the right knee obtained in September 2008 demonstrated degenerative changes within the posterior horn, medial lateral meniscus and minimal medial patellar facet chondromalcia.  No further surgery was indicated.  Attempt for the CI pain control was unsuccessful.

At the MEB narrative summary evaluation dated 4 February 2009 (performed approximately 4 months prior to separation), the physician noted the CI had received medication for neuropathic pain in large doses without significant pain relief.  He reported constant pain (6/10 intensity) that become worsen during cold weather.  The CI required a cane for ambulation and noted he also had lower back pain since 2005.  During physical examination the examiner noted the CI had an antalgic gait with a limp of the right leg.  There was tenderness and pain on palpation of the right knee patella and no evidence of knee instability.  ROM recorded flexion to 95 degrees that was limited by pain.  There was no evidence of skin color changes or temperature abnormality of the right knee in comparison to the left.

At the VA Compensation and Pension general examination dated 21 October 2008 (7 months prior to separation) ROM was recorded for right knee flexion of 120 degrees with pain beginning at 110 degrees and extension of 0 degrees.  The CI wore a right knee brace and his gait was recorded as guarded.  The July 2009 VARD noted nerve conduction study (NCS) of the right lower extremity performed on 21 May 2009, was negative for neuropathy of the lower right extremity.  The VARD also referenced VA examinations dated 12 June 2009 (2 weeks after separation), which demonstrated right knee ROM flexion of 104 degrees without pain and extension of 0 degrees without pain.  Repetition did not decrease ROM.  The examiner diagnosed right knee strain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of complex regional pain syndrome with chronic right knee pain at 20% (moderate neuritis of sciatic nerve), coded analogously 8699-8620 (neuritis), for slight quadriceps atrophy.  The VA rated the right knee strain condition at 0 %, coded 5020, citing lack of evidence of painful, limited motion.  A higher rating of 30% requires demonstration of moderately severe muscle atrophy and significant weakness of knee flexion.  The Board reviewed the findings of the MEB and noted the omitted documentation of trophic changes, absence of knee instability findings, slightly decreased ROM flexion and a 1 centimeter difference in the circumference of the right knee compared to the left (could be normal variant and not clinically significant).  The Board, after careful deliberation, assigned probative value to the VA examination (preformed 2 weeks after separation), referenced in the VARD.  That examination did not support a compensable ROM, found slight trophic change in the right knee when compared to the left knee and noted absence of findings suggestive of knee instability.  There was no recorded finding of muscle atrophy.  The NCS was negative.  Board members agreed the evidence did not support the higher rating of 30%.  Additionally, the Board noted ROM recordings at the MEB and VA were not compensable under any ROM codes.  After due deliberation in consideration of reasonable doubt (VASRD §4.3), the Board concluded that there was insufficient cause to recommend a change in the PEB’s rating determination for the complex regional pain syndrome with chronic right knee pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of mid-frequency bilateral hearing loss, history of shoulder pain, history of low back pain, recurrent hand dermatitis.  The Board’s threshold for countering fitness determinations is higher than the §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  There was no documentation of the shoulder pain, lower back pain and of recurring hand dermatitis conditions were profiled.  Although the condition of bilateral hearing loss was profiled, there was no evidence in the service treatment records that indicated the condition interfered with CI’s duty performance.  Audiology evaluation (performed 6 months prior to separation) noted the condition was very mild and amplification was not required.  All of the conditions were not judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of the above noted conditions 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 contended condition and so no additional disability ratings are 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 complex regional pain syndrome with 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 bilateral hearing loss, history of shoulder pain, history of lower back pain and history of recurring hand dermatitis 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 20140425, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
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 XXXXXXXXXXXXXXXXX, AR20150006363 (PD201402145)

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: