RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02514
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Cargo Specialist, medically separated for “chronic mechanical low back pain” and “chronic (RPPS) bilateral knee pain,” rated at 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “Lumbar strain and L. patella femoral.”  The CI’s complete submission is at Exhibit A.  

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 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 - 20060828	VARD - 20070510	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	10%	Chronic Lumbar Strain	5237	20%	20061117	
Chronic (RPPS) b/l Knee Pain…	5099-5003	0%	Patellofemoral Syndrome, L Knee	5260	10%	20061117	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Mechanical Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began after returning from deployment (in September 2005), with no associated injury or trauma.  Radiographic studies in May 2006 were normal and there was no surgical indication.  Orthopedic exams documented positive signs of iliotibial band inflammation (positive Noble’s compression test).  Despite conservative treatment, the CI’s back pain could not be adequately rehabilitated to meet the physical requirements of his military specialty, so he was referred for an MEB.  

The MEB NARSUM examination on 24 July 2006 (2 months prior to separation) noted complaints of pain localized in the lower back.  The CI denied radicular pain, tingling/prickling, or numbness in his lower extremities.  Physical exam showed mild tenderness of the muscles that parallel the spine and of both the sacroiliac joints (the bilateral joints between the spine and the pelvis).  Strength, sensation, and reflexes of the lower extremities were normal.  Provocative maneuvers to identify nerve root irritation were negative, as was testing for sacroiliac joint irritation.  At the time of the physical therapy (PT) MEB appointment on 25 July 2006, the CI reported increasing low back pain with walking.  The examiner recorded pain level 0/10 for the low back.  

At the VA Compensation and Pension (C&P) examination on 17 November 2006 (2 months after separation), the CI reported back pain that manifested in stiffness (after sitting for long periods) and weakness.  The back pain was reported to occur 7 times per day and lasted an hour per occurrence.  This pain was characterized as crushing, squeezing, aching, and oppressing in nature, and was rated at 7/10 in intensity, elicited by leaning forward and eased by sitting upright.  The CI was functioning without medication, denied receiving treatment for the condition at the time, denied incapacitation, and denied any functional impairment.  Physical exam showed no evidence of radiating pain on movement.  Testing for nerve root impingement was negative bilaterally.  Neurologic exam documented normal reflexes and sensory exam with normal strength except for 3/5 weakness in the left hallucis longus (extends the big toe).  The examiner stated that the CI “has longstanding weakness of left hallucis longus extension (since -childhood) that he is unaware of origin.  There is no sensory or other motor loss or history consistent with IVDS (intervertebral disc syndrome).”  Other results are depicted in the ROM chart above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain 10% coded analogous to 5237 (lumbosacral strain), citing “tenderness to palpation.”  The VA rated the low back pain 20% coded 5237, based on the VA C&P examination 2 months after separation, citing muscle spasm or guarding severe enough to result in an abnormal gait.  

There was a disparity between examinations with implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, and carefully reviewed the entire file for corroborating evidence.  All of the evidence prior to separation approximated the disability level noted at the PT and NARSUM examinations.  The post-separation VA exam was the single exam proximate to separation documenting either spasm or antalgic gait and that exam maintained a normal ROM.  The source C&P exam also did not specify if the abnormal gait was attributed to the back or knee conditions.  The VA exam was considered an outlier to the remainder of the evidence in the record.  The Board adjudged that the NARSUM/PT exam had the highest probative value for rating.  The Board agreed that a 10% rating, but no higher, was justified for tenderness reported on the NARSUM exam, forward flexion greater than 60 degrees but not greater than 85 degrees and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT MEB examination.  There was no documentation of incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment due to the back which would provide for additional rating.  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 low back pain.  

Chronic (RPPS-Retropatellar Pain Syndrome) Bilateral Knee Pain.  According to service treatment records and the MEB NARSUM, the CI’s bilateral knee pain began in 2001 and was attributed to running.  Radiographic studies performed in April 2006 were normal and there was no surgical indication.  Despite conservative treatment, the CI’s bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of his military specialty, so he was referred for an MEB.  

At the MEB NARSUM exam on 24 July 2006 (2 months prior to separation), the CI reported pain behind both kneecaps, and denied weakness or locking of the knees.  Physical exam noted pain on compression of the kneecaps and with distraction (of the kneecap).  There was no fluid buildup, loose ligaments, or tenderness.  Testing for instability and torn ligaments was negative.  The NARSUM diagnosis was chronic patellofemoral pain syndrome.  

At the VA C&P examination on 17 November 2006 (2 months after separation), the CI reported symptoms of knee “stiffness and heat,” lack of endurance, fatigability, and constant, localized knee pain rated at 7/10 intensity.  The pain would come on with no provocation and ease with rest or over time.  The CI denied incapacitation due to knee pain and reported no functional impairment from the condition.  Physical exam showed an “antalgic gait favoring right,” with neither knee showing signs of excess fluid, weakness, tenderness, redness, heat, abnormal movement or guarding.  Left knee function was limited by pain on repetitive motion, but the limitation was not specified beyond the ROM.  Right knee function was not limited by repetitive motion.  All testing for both knees was normal.  Radiographic study of the left knee was normal (no radiographic study was performed for the right knee).  

The PEB rated the bilateral knee pain under a single 0% disability rating, coded analogously to 5003 (arthritis, degenerative), citing full range of motion and normal imaging.  The VA rated the left knee condition 10% (coded 5260 (leg, limitation of motion of), citing painful motion.  There was no discussion regarding a claim or rating for the right knee, until later VARDs, when the VA awarded a 10% right knee (5260 code) rating effective the date of the CI’s claim in 2014.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows individual ratings for each compensable joint in accordance with §4.7 (higher of two evaluations).  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  In this case a bilateral knee condition was determined to fail retention standards by the NARSUM, was profiled, and was implicated by the commander’s statement.  Members agreed that the evidence of the record reasonably supported that each knee was separately unfitting.  

The Board directed attention to its rating recommendation based on the above evidence.  The PT MEB exam was comprehensive and aligned with the preponderance of the evidence of record.  The Board majority adjudged that the PT MEB exam had the highest probative value for rating at separation.  The Board deliberated if pain with patellar distraction coupled with the CI’s symptoms and clinical diagnosis of chronic patellofemoral pain syndrome provided sufficient evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Coupled with the differences in active and passive ROMs, the Board majority adjudged that there was sufficient reasonable doubt to warrant the award of 10% for each knee joint.  

There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), frequent locking with effusions or any indication of dislocated meniscus or loose body (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 was therefore no pathway to any rating higher than 10% for either knee joint.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends a disability rating of 10% for the left knee pain, coded 5299-5003, and by a majority recommended a disability rating of 10% for the right knee pain, also coded 5299-5003.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic (RPPS) bilateral knee pain condition, the Board unanimously recommends that each knee be separately unfitting with a disability rating of 10% for the left knee condition, coded 5299-5003; and by a majority vote with a disability rating of 10% for the right knee condition, also coded 5299-5003; both IAW VASRD §4.71a.  The single voter for dissent recommended modification and did not elect to submit a minority opinion.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain…	5299-5237	10%	
Chronic (RPPS) b/l Knee Pain…	Left Knee	5099-5003	10%	
	Right Knee	5099-5003	10%	
COMBINED w/BLF	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM   FOR Commander

SAMR-RB

SUBJECT:   Department  of Defense  Physical  Disability  Board of Review  Recommendation
for XXXXXXXXXX,  AR20160007506   (PD201402514)

1.  Under the authority  of Title  10, United States Code, section  1554(a),  I approve  the
enclosed  recommendation   of the Department  of Defense  Physical  Disability  Board of Review  (DoD PDBR)  pertaining  to the individual  named in the subject  line above to re- characterize  the individual's  separation  as a permanent  disability  retirement  with the combined  disability  rating of 30% effective  the date of the individual's  original  medical separation  for disability  with severance  pay.

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:

a.  Providing  a correction  to the individual's  separation  document  showing  that
the individual  was separated  by reason of permanent  disability  retirement  effective  the date 
of the original  medical  separation  for disability  with severance  pay.

b.  Providing  orders showing that the individual  was retired with permanent disability  effective  the date of the original  medical  separation  for disability  with severance  pay.

c.  Adjusting  pay and allowances  accordingly.   Pay and allowance  adjustment  will
account  for recoupment  of severance  pay, and payment  of permanent  retired pay at 30% effective  the date of the original  medical  separation  for disability  with severance
pay.

d.  Affording  the individual the opportunity  to elect Survivor  Benefit  Plan (SBP)
and medical TRICARE  retiree options.

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:

Enclosure
CF:
( ) DoD
PDBR
( ) DVA