RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02687
BRANCH OF SERVICE:  Army		 SEPARATION DATE:  20050723

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cavalry Scout, medically separated by the Informal Physical Evaluation Board (PEB) for “chronic LBP,” “left knee pain” and “exercise induced asthma” , rated 10%, 10% and 0%,  respectively with a combined Service disability rating of 20%.  

CI CONTENTION:  “Please consider all 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 - 20050723	VARD - 20060519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5243-5299-5237	10%	DDD Lumbar Spine	5242	10%	20060314	
Left Knee Pain	5259	10%	L Knee Strain S/P Meniscus Tear	5099-5019	10%		
Exercise Induced Asthma	6602	0%	Exercise Induced Asthma	6602	10%		
Depressive Disorder	Not Unfitting	Major Depressive Disorder	9434	30%	20060310	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic LBP.  The first record in evidence for the LBP condition is a primary care note dated 6 August 2002 in which the CI reported a 20-day history of pain since a field exercise.  X-rays showed mild disc space narrowing (degenerative disc disease, DDD) at L5-S1.  X-rays of the thoracolumbar spine on 30 April 2003 showed 23 degrees of levo-scoliosis (curvature to the left).  An MRI on 14 August 2003 showed DDD at L3-4 and L4-5.  The thoracic spine was noted to have mild DDD from T10-11 to T11-12, but normal alignment.  At an orthopedic follow-up appointment on 11 December 2003, a 2-level discectomy at L3-4 and L4-5 was recommended and then performed on 7 January 2004.  The CI was referred to physical therapy (PT) for rehabilitation following surgery.  In orthopedics on 21 May 2004, he was noted to have a normal neurological examination and pain free motion.  Flexion was 80 degrees.  The ROM was stable at a follow-up on 16 July 2004.  The CI continued to report pain and the MRI was repeated on 9 August 2004.  It was consistent with recurrent herniation and scarring; nerve root impingement was not present though.  The narrative summary (NARSUM) was dated 18 November 2004, 8 months prior to separation.  The CI reported occasional LBP with flares every 2 weeks.  He reported significant benefit from the surgery.  The neurological examination was normal.  One sign of non-organic pain was present.  The ROM was accomplished in PT 10 days earlier and is charted below.  The CI was evaluated in neurology for a possible closed head injury (in 1999) on 15 March 2005, 4 months prior to separation.  His motor function and gait were normal.  The VA Compensation and Pension (C&P) examination was performed on 14 March 2006, 8 months after separation.  The CI reported that he was unable to walk over a few yards (however, he reported no limitation at the knee examination the same day) and that he had lumbar spasm.  On examination, the gait and posture were normal.  Abnormal curvature and atrophy were absent.  Mild guarding and spasm were present, but did not result in an abnormal gait or spinal contour.  Pain was present at the end of motion.  The neurological examination was normal.  The goniometric range of motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	ORTHO ~14 Mo. Pre-Sep	ORTHO ~11 Mo. Pre-Sep	MEB (PT) ~8 Mo. Pre-Sep	VA C&P ~6 Mo. Post-Sep	
Flexion (90 Normal)	80	80	40 (40/38/38)	90	
Combined (240)		---	180	240	
Comment	Pain free motion	Nml neurological exam			
§4.71a Rating	10%	10%	20%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back condition at 10%, coded 5243 5299-5237 (intervertebral disc syndrome and analogous to lumbosacral strain) and 5242 (degenerative arthritis of the spine), respectively.  The MEB ROM supports a 20% rating, but is an outlier from multiple other measurements before and after separation.  The others support a 10% rating for either limited or painful motion.  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 chronic back pain condition.  

Left Knee Pain.  The record shows that the CI had arthroscopy of the left knee in 1999 and in February 2002.  The MEB physical examination on 21 October 2004 recorded a normal examination other than scars from the surgery.  The NARSUM addendum dated 8 February 2005 noted that there no special findings for the knee other than the surgical scars.  At the VA C&P examination performed 6 months after separation, the examiner noted the history of previous surgery.  The history reported by the CI was not completely consistent with the historical record.  He reported that he could stand for 15-30 minutes, but had no limitations in walking.  Subjective instability, pain, weakness, and stiffness were present.  His gait and ROM were normal and pain was not present until the end of motion.  There was no loss of motion with repetition.  X-rays were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the knee at 10%, coded 5259 (removal of meniscal cartilage) and 5099-5019 (analogous to bursitis), respectively.  Neither code offers an advantage to the other.  Absent instability, locking of the joint, or compensable limitation in motion, the Board found no route to a higher 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 left knee pain condition.  

Exercise Induced Asthma.  The CI was first evaluated for shortness of breath associated with exercise in 1998, reporting symptoms since October 1997.  He was evaluated with pulmonary function testing (PFTs) during exercise and found to have a reduction in values consistent with exercise induced asthma (primarily running).  His pre-exercise values were normal.  Medications did not improve his symptoms.  However, he was placed on a profile for his knee around 13 July 1998 and this was no longer problematic as the provocative trigger had been removed (running).  The NARSUM addendum was dated 8 February 2005.  His lungs were clear and respirations normal.  He reported no duty impairment, but as noted, his profile precluded running.  He was able to swim 2 miles without symptoms.  At the VA examination, the CI reported that he was no longer running and no longer had symptoms.  His lungs were clear and respiratory rate normal.  A chest X-ray was normal.  Mild obstruction was noted (the hallmark of asthma) along with severe air trapping.  The lung volume loop was uninterpretable.  The pulmonary function tests (PFT) in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Pulmonary Exam	Pulmonary 7 years prior to separation 	RT ~2 Mo. Pre-Sep	VA C&P ~6 Mo. Post-Sep	
FEV1 (% Predicted)	103	101	84	
FEV1/FVC	90	107	71	
Meds	None; FVC 4.85	None; FVC 5.15	None; FVC 4.69.  Invalid test; see discussion below	
§4.97 Rating	0%	0%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the exercise induced asthma at 0%, coded 6602 (asthma).  The VA also used the 6602 code, but rated the condition at 10% citing the FEV1/FVC ratio of 71%.  The Board noted that the PEB values were more proximate to separation than the VA measurements and also more consistent with the baseline values in 1998 and with the normal pulmonary examination and lack of symptoms.  The Board also noted that the FVC measured on the VA examination was the lowest of the three values in evidence and that there was no indication of a respiratory problem to explain the reduction.  Typically, if abnormal values are obtained, these are repeated to verify the validity of the examination.  Accordingly, the VA values may not represent a “best effort” by the CI.  The validity is also called into question with the note of severe air trapping (without an etiology) and an uninterpretable flow volume loop.  These findings were discussed with a pulmonologist who opined that the test was not valid and should have been repeated.  Accordingly, the Board determined that the PEB values had a higher probative value and were used for rating purposes.  These support a 0% rating which was adjudicated by the PEB.  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 exercise induced asthma condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the depressive disorder condition was not unfitting.  The commander made no mention of impairment from a mental health condition.  The MEB determined that it failed retention standards.  However, the mental health NARSUM clearly noted that the depression was resolving on medications and met retention stands.  Subsequently, the CI underwent neuropsychological testing (for a cognitive disorder) which was thought to date to his childhood and not reflect a reported head injury.  The CI also endorsed a moderate to severe level of depressive symptoms.  The depressive disorder was reviewed and considered by the Board.  The evidence was mixed, but there was no clear performance based evidence from the record that it 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 depressive disorder and so no additional disability rating is recommended.

BOARD FINDINGS.  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the exercise induced asthma condition and IAW VASRD §4.100, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended depression 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 20140424, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

JUL 19 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20160008553 (PD201402687)

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