RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02848
BRANCH OF SERVICE:  Army	BOARD DATE:  20150508
SEPARATION DATE:  20040920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Health Care Specialist) medically separated for back and bilateral knee conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent L4 profile and referred for an Medical Evaluation Board (MEB).  Bilateral knee patellofemoral pain syndrome (PFPS), chronic mechanical low back pain (LBP) and sacroilitis-improved were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified hypertension, migraine headaches and paroxysmal tachycardia for PEB adjudication.  The Informal PEB adjudicated mechanical LBP and bilateral PFPS as unfitting, rated 10% and 10% each with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.

CI CONTENTION:  The applicant makes no specific contention in her application.  Her 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 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 IPEB – Dated 20040708	VA* - (~1 Mo. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain Syndrome	5099-5003	10%	Degenerative Arthritis, Right Knee	5003	10%	20040816	
			Patellofemoral Pain Syndrome, Left	5009-5019	10%	20040816	
Mechanical Low Back Pain	5237	10%	Mechanical Low Back Pain	5237	10%	20040816	
Sacroilitis	Not Unfitting					
Hypertension	Not Unfitting	Hypertension	7101	0%	20040816	
Migraine Headaches	Not Unfitting	Fibromyalgia with Migraine Headaches & Depression	5025	20%	20040816	
Paroxysmal Tachycardia	Not Unfitting	Heart Condition	7099-7005	NSC	20040816	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  20%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20041109 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Bilateral Knee Condition.  The CI developed bilateral knee pain due to activity performed in basic training in February 2003.  Few documents stated her falling upon her knees with physical activities.  Initial X-rays were normal and her diagnosis was retro-patellar pain syndrome and clinical left-sided bursitis.  A “mild” effusion was present in the left knee.  A bone scan performed on 16 July 2003 revealed bilateral stress-related changes within the knees.  Despite aggressive physical therapy (PT), medications, restrictions, injections, and acupuncture, her bilateral knee pain persisted.  She was permanently profiled in June 2004 with bilateral knee pain as one of two musculoskeletal diagnoses.  The commander’s letter implicated the CI’s bilateral knee condition as one of two diagnoses that caused her the inability to perform basic military training duties.  She was referred for an MEB.  At the MEB narrative summary (NARSUM) examination performed on 18 February 2004 (4 months prior to separation), the CI endorsed constant bilateral knee pain worsened with prolonged sitting, standing, walking, squatting, lifting, kneeling, and impact activities.  Her physical examination revealed bilateral knee tenderness.  Patellar grind was present.  Meniscus and instability testing did not reveal abnormalities.  There was decreased range-of-motion (ROM) to both knees secondary to pain.

At the VA Compensation and Pension general examination performed on 16 August 2004 (a month prior to separation), the CI reported an inability to bend or stand for prolonged periods for 2 weeks when her knees are swollen.  The VA physical evaluation revealed bilateral knee tenderness with pain and decreased ROM.  The goniometric 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.

Knee ROM
(Degrees)	PT Exam (MEB)
~7 mos Pre-Sep
(20040218)	VA C&P 
~1 Mo. Pre-Sep
(20040816) 	
	Left	Right	Left	Right	
Flexion (140 Normal)	120	120	120	130	
Extension (0 Normal)	0	0	0	0	
Comment	Painful motion	Painful motion	Painful motion	Painful motion	
§4.71a Rating	10%	10%	10% 	10% 	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a single analogous 10% rating under 5003 code (Degenerative arthritis), whereas the VA separately rated both knees with 5003 at 10% for the right knee and an analogous rating under code 5019 (Bursitis) at 10% for the left knee, each citing painful motion.  The Board first considered whether each knee condition remained separately unfitting, having decoupled them from the combined PEB adjudication.  Although the bone scan findings of stress changes were equivocal to both knees, the recorded evidence of the presence of a joint effusion reflected that the left knee, additionally diagnosed with bursitis, was associated with more pathology than the right knee.  The Board considered the absence of an effusion in the right knee and raised the question of whether the right knee was reasonably justified as separately unfitting near the time of separation.  All parameters considered, excepting the “mild” effusion, the attendant physical exam and radiologic attributes were nearly identical.  The Board considered and agreed that it would be highly speculative to conclude that the disability confined to either single knee would not have rendered the CI incapable of performing her MOS.  Additionally, the Board found it reasonable to surmise that the combination of pathology from both knees rendered her unfit.  While there was no evidence of compensable limitation of motion, the Board agreed that the PEB’s 10% “bundled” rating was supported by painful motion (§4.59) as indicated in prior to separation examinations.  The Board also agreed with the PEB’s analogous coding choice of 5099-5003 noting the absence of ankylosis, instability, frequent locking, or surgical intervention.  Therefore, 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’s adjudication for the bilateral knee condition.

Low Back Pain (subsumes Sacroilitis).  Absent direct trauma, the CI developed LBP in May 2003.  Despite a variety of conservative treatment measures, her back pain continued and worsened.  In October 2003, she was hospitalized (3 days) for pain control.  Radiology tests to include X-rays, a computerized tomography (CT) scan, and magnetic resonance image which were without abnormal findings.  A bone scan of the pelvic region performed in October 2003 “suggested” inflammation of the left sacral-iliac joint; however, a repeat scan in January 2004 was normal.  Her back pain condition remained and was a listed diagnosis on her profile and MEB.  At the MEB NARSUM examination, 4 months pre-separation, she endorsed current 5/10 pain scaled LBP.  Her physical exam was normal excepting decreased and painful motion.  Waddell signs were present at 4/5 (Waddell signs are “indicators” of non-organic causes of pain).  The goniometric 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)	PT Exam
~7 mos Pre-Sep
(20040218) 	VA C&P
~1 Mo. Pre-Sep
(20040816) 	
Flexion (90 Normal)	(75) 75/75/75	90	
Extension (30)	(15) 15/15/15	25	
R Lat Flexion (30)	(20) 20/20/20	30	
L Lat Flexion (30)	(25) 25/25/25	30	
R Rotation (30)	(30) 60/60/60	30	
L Rotation (30)	(30) 60/60/60	30	
Combined (240)	195	235	
Comment	Painful motion 	Painful motion	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA listed the same diagnosis; utilized the same 5237 code (Lumbosacral strain) and rated at 10%.  Board members agreed that near the time of service separation, sufficient evidence of painful motion was present to justify the service’s 10% rating IAW VASRD §4.59.  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’s adjudication for the low back condition.
Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension, migraine headaches, and paroxysmal tachycardia were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (Reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The three identified conditions were not profiled or implicated in the commander’s statement and 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 these 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 any of the contended conditions 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 bilateral knee condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension, migraine headache, and paroxysmal tachycardia 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 recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140507, 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 XXXXXXXXXXXXXXXXXX, AR20150018830 (PD201402848)

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