RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX			            CASE:PD-2014-02384
BRANCH OF SERVICE:  Army	Separation Date:  20091215

SUMMARY OF CASE:  Data extracted from the available evidence of record indicates this covered individual (CI) was an active duty E-2 (Trainee) medically separated for right knee and back conditions.  These could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards, so he was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The knee and back conditions, characterized as “right knee bone contusion” and “low back pain”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions for PEB adjudication (see rating chart below).  The PEB adjudicated “right knee bone contusion…” and “lumbosacral strain…” as unfitting, each rated 10% (20% combined), with application of the Veteran’s 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 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:  

Service PEB – Dated 20091205	VA* - (6 Wks. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Bone Contusion…	5099-5003	10%	Subluxation, Right Knee	5257	20%	20100128	
			Right Knee Strain	5260-5024	0%		
Lumbosacral Strain…	5237	10%	Lumbosacral Strain	5237	10%		
Mild Scoliosis	Not Unfitting	No VA Entry	
Occipital Scar			
Other Conditions x 0 (Not In Scope)	Other x 1 	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20100508 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Knee Condition.  The CI injured his right knee in 2009.  He underwent physical therapy (PT); however, the medial joint line and mild medial-tibial pain persisted.  Right knee MRI showed a small tear of the medial meniscus with a bone bruise.  The PT note dated 27 May 2009 documented that the CI reported swelling and pain along the medial knee.  There were physical exam findings of right knee pain with medial meniscus tear limits; 4/5 quad and hamstring muscle strength (normal 5/5); “stable Lachmans, ant drawer, varus/valgus” (test for instability); and painful medial joint line and tibial plateau.  The left knee was not examined for comparison.  The MEB Narrative Summary (NARSUM) exam approximately 3 months prior to separation documented that the CI continued to have right knee pain rated at 4/10 with any increased activity.  He had a functional limitation of an inability to run.  He had increased pain with going up and down stairs and aggravated knee pain with push-ups and sit-ups.  The MEB NARSUM physical exam documented tenderness to palpation (TTP) over the medial tibial plateau/medial femoral condyle and a positive McMurray's maneuver (tests for meniscal injury).  There was a “negative Lachman’s and negative drawer” and negative varus-valgus testing (lateral stability).  Range-of-motion (ROM) testing was 0-130 degrees (normal 0-140).  The left knee was not examined for comparison.  Findings are summarized in the chart below.  The PEB’s disability description stated that the CI had a “1A Lachman’s” indicating the NARSUM exam and AHLTA note dated 27 May 2009 as source information.  However, neither source documented an abnormal Lachman’s test (specifically documented “stable Lachmans, ant drawer, varus/valgus” and “negative Lachman’s and negative drawer” respectively).  

The VA Compensation and Pension (C&P) exam approximately 6 weeks after separation documented persistent symptoms of pain and intermittent stiffness on a daily basis with kneeling, squatting and walking more than 20 or 30 minutes.  The pain was rated at 4/10 and lasted for several hours.  After walking he would have a flare of knee pain weekly for approximately three to four hours rated at 6-7/10.  The history stated there was “pain and stiffness but no locking, swelling, or instability.”  The VA C&P physical exam findings showed non-painful ROM of 0-140 degrees (normal) with a mildly antalgic gait, mild tenderness over the medial joint line, and negative Lachman’s and Mc Murray's tests.  A right knee X-ray done as part of the C&P exam showed moderate lateral subluxation and tilt of the patella (kneecap).  The knee was stable to varus-valgus (lateral) testing.  

There were range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.  

Right Knee ROM
(Degrees)	MEB ~3 Mo. Pre-Sep	MEB Form DD-2808
~2 Mo. Pre-Sep	VA C&P ~6 Wks. Post-Sep	
Flexion (140 Normal)	130	No ROM’s	140	
Extension (0 Normal)	0		0	
Comment	Goniometer; tender to palpation (TTP); McMurray's maneuver discomfort localizes medially	“Weakness right knee,” TTP medially	Gait mildly antalgic; mild TTP over medial joint line; no instability; Lachman’s and Mc Murray's negative; see text	
§4.71a Rating	10%	10%	10% (VA 20% subluxation + 0% strain/)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right knee condition analogous to 5003 (Arthritis, degenerative [hypertrophic or osteoarthritis]) and rated at 10% for painful motion.  The VA dual coded the knee 5257 (knee, other impairment of:  Recurrent subluxation or lateral instability and rated at 20% (moderate) plus right knee strain condition as 5260 (leg, limitation of flexion) with 5024 (tenosynovitis) rated 0%.  
The Board considered meniscal coding under 5259 (cartilage, semilunar, removal of, symptomatic) or 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint).  There was insufficient evidence of frequent episodes of “locking,” pain, and effusion into the joint for coding under 5258 (20%) and rating under 5259 (10%) would offer no benefit to the CI as meniscal coding includes painful motion.  There was no compensable limitation of motion absent consideration of VASRD §4.59 (painful motion) for a 10% rating based on the service treatment record.  The VA exam did not document painful or pain-limited motion. The Board next considered if dual rating of the knee for subluxation/instability (code 5257) was warranted.  The PEB indicated a 1A Lachman’s (positive) which indicates possible or slight knee instability; however, the source documents - AHLTA note and NARSUM did not indicate any knee instability.  The VA examiner did not find any evidence of knee instability on exam, although the X-rays showed moderate subluxation of the kneecap. The Board discussion centered on whether there was sufficient evidence of knee instability for rating; weighing the CI’s lack of instability symptoms, stable service and VA knee exams, and the VA radiographic evidence of the patella.  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 knee condition.  

Back Condition (Lumbosacral Strain and Mild Scoliosis):  The CI developed back pain in 2009.  Scoliosis (abnormal curve of the spine) was annotated on the entrance physical.  A thoracolumbar spine X-ray done in January 2009 showed thoracolumbar scoliosis.  A lumbar spine X-ray done in June 2009 was normal.  The MEB NARSUM exam documented lower back pain localized over the right lumbar area with radiation into the buttock area, and some tingling and numbness in the feet bilaterally.  The CI reported that the back pain was aggravated by sitting or standing greater than 20 minutes.  The MEB NARSUM examiner documented forward flexion of 90 degrees (normal) and a combined range-of motion (ROM) of 200 degrees (240 normal), along with tenderness.  Mild dextroscoliosis was noted.  Lower extremity strength, sensation, and reflexes were normal.  The VA C&P exam documented intermittent daily low back pain, stiffness, fatigability and lack of endurance but no weakness.  The back pain occurred after lifting, bending or getting up and out of a chair.  The pain radiated frequently into the right buttocks with associates tingling; however, there was associated leg weakness, numbness or tingling.  The CI reported back pain flares approximately once a month after excessive stooping or bending with pain rated at 6-7/10.  ROMs were at VA normal limits with pain on repetition.  The gait was mildly antalgic and lower extremity strength, sensation, and reflexes were normal.  The examiner stated that there was no radiculopathy.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both coded the back condition as 5237 (lumbosacral or cervical strain) and rated at 10%.  The “General Rating Formula for Diseases and Injuries of the Spine” considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.”  The MEB documented a combined ROM of 200 degrees and tenderness and the VA exam documented painful motion.  The CI met the 10% rating criteria of “combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees” and/or “localized tenderness not resulting in abnormal gait or abnormal spinal contour.”  The Board noted the CI had scoliosis (abnormal spine curve), however, this was not due to guarding or muscle spasm.  

Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The sensory component in this case had no functional implications.  There was no motor impairment on exams.  Since no evidence of functional impairment existed in this case, the Board cannot support a recommendation for additional rating based on nerve impairment. 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 back condition.  

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were mild scoliosis and an occipital (head) scar.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is preponderance of the evidence but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The mild scoliosis condition was considered under the unfitting and rated lumbosacral strain condition above.  The occipital (head) scar condition was not profiled; implicated in the commander’s Statement; or judged to fail retention standards.  There was no indication from the record that the occipital (head) scar 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 either the mild scoliosis or the occipital scar contended conditions and, therefore, 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 knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended mild scoliosis and an occipital scar 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 2014-02384 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160004493  (PD201402384)

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

CC' ·.
( ) DoD PDBR
( ) OVA