RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02905
BRANCH OF SERVICE:  Army                                                            SEPARATION DATE:  20041217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard, E6, Combat Engineer, medically separated for “ankle and knee,” and “low back” conditions rated 10% and 0%, respectively, with a combined disability rating of 20%.  The unfitting neck pain was determined to have existed prior to service (EPTS) and was not rated.

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 – 20041018	VARD - 20071012	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Ankle and Knee Pain, Bilateral	5003	10%	RPPS, Left Knee	5010-5260	10%	20050822	
			RPPS, Right Knee	5010-5260	10%		
			Degenerative Changes, L Ankle	5271	0%		
			Degenerative Changes, R Ankle	5271	0%		
Recurrent LBP	5299 5237	10%	DDD, Lumbosacral Spine	5242	20%		
Chronic Neck Pain…DDD	5299 5237	--%	DDD, Cervical Spine	5242	20%		
Migraine without Aura	Not Unfitting	Recurrent Vascular Headaches…	8100	0%		
Depressive Disorder NOS…		Depressive Disorder NOS	9424	30%	20050826	
Mild Degenerative Arthritis of the Left ACJ		Degenerative Joint Disease, L Shoulder…	5201	10%	20050822	
Tinnitus		Bilateral Tinnitus	6260	10%	20050826	
Elevated Lipids		No VA placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	
*Derived from VA Rating Decision (VARD) dated 20020060425 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Recurrent Bilateral Ankle Pain.  At the periodic medical examination (age 40) performed on 29 April 2002, the CI denied bone or foot trouble and had a normal examination other than knee tenderness.  At retention medical examination performed on 13 March 2003, 2 days prior to accession, the CI again denied bone or foot trouble and had a normal examination other than an appendectomy scar.  The CI was activated on 15 March 2003.  A primary care note dated 7 November 2003, for the MEB examination, noted a normal gait and an “essentially normal examination today.”  At the first (of two) MEB examinations dated 4 November 2003, the CI reported multiple sprained ankles.  This is the first record found in evidence regarding the ankle conditions.  On examination, tenderness, swelling, and redness were absent bilaterally.  The ankles were stable.  Motor function was noted to be “good” bilaterally.  The orthopedic addendum to the narrative summary (NARSUM) was dated 24 December 2003, 12 months prior to separation.  The CI reported bilateral ankle pain since May of 2003.  He reported occasional morning stiffness and a prior “severe” sprain treated with casting for 6 weeks.  He also reported a 30-40 pound weight gain since activation.  He denied instability.  A prior history of a spur excision on the left (“years ago”) was recorded.  On examination he was noted to have a normal gait and a normal tandem gait.  He was recorded as having full range of motion (ROM), but the values recorded (10 degrees dorsi-flexion and 30 degrees plantar flexion) were less than VA normal values (20 and 45, respectively).  Very mild signs of instability were noted on the left ankle.  Neither ankle was tender to touch.  The NARSUM was dated 26 April 2004, 8 months prior to separation, referenced an examination dated 22 January 2004, 11 months prior to separation.  It essentially duplicated the orthopedic history and physical above.  He was thought to have chronic ankle pain with a history of prior trauma.  At the MEB examination dated 18 June 2004, 6 months prior to separation, the CI reported persistent ankle pain.  The MEB physical examiner noted that the ankles were non-tender and stable in all directions.  In a neurology evaluation for headaches on 21 July 2004, the CI was noted to have a normal gait.  X-rays on 27 August 2004 were stable compared to prior X-rays dated 3 December 2003 which showed an area of post-traumatic bone formation in the soft tissue on the left (consistent with an old sprain).  In physical therapy (PT) the same day, he reported that (his) “knees and ankles were killing me.”  On examination, he was noted to have very tender heel cords and limited dorsi- and plantar flexion.  At a follow-up PT appointment dated 13 September 2004, he reported improvement with pool therapy and also noted improvement in plantar fasciitis which was being treated with inserts and stretching.  Dorsi-flexion was limited to 0 degrees bilaterally whereas plantar flexion was 50 degrees.  Toe and heel walking were both impaired.  His gait was short and choppy; he was noted to be sore from the plantar fasciitis.  The medical officer noted that dorsi-flexion would stretch the plantar fascia, reducing the probative value of these measurements.  At the VA Compensation and Pension (C&P) examination performed on 22 August 2005, 8 months after separation, the CI reported that his ankle pain had been present for many years and that he had degenerative arthritis on X-ray.  He was using orthotics for his bilateral plantar fasciitis.  On examination, he had some pain on manipulation of the ankles, but normal alignment and ROM with no reduction after repetition.  The gait was slightly antalgic (avoiding pain), but this was not attributed specifically to any specific condition (including the plantar fasciitis, ankles, knees, and back).  However, it was listed under the neck and back discussion.  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.  

Ankle ROM
(Degrees)	MEB ~11 Mo. Pre-Sep	VA C&P ~8 Mo. Post-Sep	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	10	10	20	20	
Plantar Flexion (45)	30	30	45	45	
Comment	Nml gait; noted as full ROM	Pain free motion	
§4.71a Rating	10%	10%	0%	0%	

The Board first considered if the evidence supports a finding that either ankle was separately unfitting.  It noted that the majority of the evaluations record a normal gait.  One examination notes that the plantar fasciitis was problematic and another did not assign the gait problem to any particular area.  However, the MEB did forward the ankles as failing retention standards and the final profile also listed the ankles, supporting a finding that the ankles were each separately unfitting.  The Board then directed its attention to its rating recommendation based on the above evidence.  The PEB combined the ankles and knees into a single unfitting condition, rated 10%, and coded 5003 (degenerative arthritis).  The code 5003 supports a 10% rating for the ankles and knees as a combined rating for painful motion and limited motion.  The Board considered if a higher rating was achieved with another coding option, specifically 5271 (limitation in ankle motion) which was used by the VA to support separate 0% ratings for each ankle.  A moderate limitation supports a 10% rating and the limitation in measured motion is consistent with this; however, the examiner specifically noted that the ROM was full and the gait was normal.  The VA examination had normal ROM.  The majority of examinations showed a normal gait.  The preponderance of the evidence does not support a moderate impairment and a separate 10% rating using the code 5271.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral ankle condition.  

Recurrent Bilateral Knee Pain.  The record shows that the CI was under treatment in February 2002 for bilateral knee pain.  X-rays were essentially normal.  An orthopedic appointment on 18 February 2002 documented subjective pain with increased activities and stairs.  The CI also endorsed popping and clicking, but denied giving way or locking.  He reported the onset as 1983.  On examination, he had tenderness over the patellar (kneecap) tendons and crepitus (an audible or sensible grinding on manipulation) with flexion and extension.  The examination was otherwise normal.  X-rays were also unremarkable.  Due to persistent pain, bilateral MRIs were accomplished on 8 April 2002 and were normal.  At a follow-up appointment on 24 April 2002, he was noted to have tenderness over the patellae and the insertions of the ligaments into the lower leg.  The examination, including ROM, was otherwise normal.  At the periodic medical examination (age 40) performed on 29 April 2002, the CI denied knee trouble, but had bilateral knee tenderness.  At retention medical examination performed on 13 March 2003, 2 days prior to accession, knee problems were not noted and the examination was normal other than an appendectomy scar.  The CI was activated on 15 March 2003.  In primary care on 7 August 2003, the CI reported aggravation of his longstanding knee pain with running for the past 6 weeks.  The examination remained essentially normal.  X-rays that day showed bilateral enthesophytes (bony projections at the tendon attachment consistent with chronic pathology) in the quadriceps tendon.  On 22 September 2003, he was noted in PT to have a normal examination other than crepitus bilaterally.  A primary care note dated 7 November 2003, for the MEB examination, noted a normal gait and an “essentially normal examination today.”  At the first MEB examination dated 4 November 2003, the CI reported knee pain since 1983 and the use of supports.  The examination was basically normal without swelling or tenderness, and with full ROM.  The knees were stable and without signs of meniscal irritation.  The orthopedic addendum to the NARSUM, 12 months prior to separation, recorded a 20 year history of bilateral knee pain with recent aggravation from running after activation.  A positive patellar grind was normal, but the ROM was normal and the knee stable.  Significant crepitus was absent.  Signs of meniscal irritation were not recorded.  He was thought to have chronic retro-patellar pain syndrome.  The NARSUM was dated 26 April 2004, 8 months prior to separation, referenced an examination dated 22 January 2004, 11 months prior to separation.  It duplicated the above orthopedic assessment.  At the MEB examination dated 18 June 2004, 6 months prior to separation, the CI reported constant knee pain which increased with activity.  The MEB physical examiner noted some crepitus, but an otherwise unremarkable examination.  The ROM was partially illegible, but appeared to be FROM (full ROM).  In a neurology evaluation for headaches on 21 July 2004, the CI was noted to have a normal gait.  A PT visit on 27 August 2004 noted that the CI had painful knees increased the past 2 weeks with the new pool program (for rehabilitation).  The insertion of the patellar tendons into the lower leg was tender, but the knee was stable and without signs of meniscal irritation.  There were no further clinical visits for the knees prior to separation, although the CI was seen for other conditions.  At the VA C&P examination performed 8 months after separation, the CI reported bilateral knee pain since 1983 and the use of an assistive device for increased activity.  On examination, there was neither swelling nor an effusion (fluid in the joint).  The knees were stable and meniscal signs were not recorded.  The 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)	MEB ~11 Mo. Pre-Sep	VA C&P ~8 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	140	140	120	120	
Extension (0 Normal)	0	0	0	0	
Comment	Painful motion not documented	The CI could squat to 130 with pain; when seated, flexion was 120 degrees.	
§4.71a Rating	0%	0%	10% under 5003	

The Board first considered if the evidence supports a finding that either knee was separately unfitting.  Both knees were profiled and both were noted to fail retention standards.  The evidence supports a finding that each was separately unfitting.  The Board then directed its attention to its rating recommendation based on the above evidence.  The ROM values do not support a rating higher than 0%.  There was no evidence for instability or meniscal disease.  Painful and limited motion, present on some examinations, with abnormal X-ray findings does support a rating under the code 5003, used for the ankles.  However, this code is for 2 or more major joints.  Accordingly, a 10% rating for the ankles and knees is supported under code 5003.  The Board found no route to a higher rating.  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 bilateral knee condition.  

Recurrent Low Back Pain.  At the periodic medical examination (age 40) performed on 29 April 2002, the CI denied back pain.  The physical examination was normal.  At retention medical examination performed on 13 March 2003, 2 days prior to accession, the CI again denied back pain and had a normal examination other than an appendectomy scar.  The CI was activated on 15 March 2003.  The first record for the low back pain (LBP) condition was an X-ray report dated 8 August 2003 which noted a history of LBP for years.  It showed a slippage of the L5 vertebrae on S1 (spondylolisthesis) with associated degenerative joint disease (DJD) and degenerative disc disease (DDD).  In primary care that same day he was noted to have a normal gait, ROM, and neurological examination.  In PT on 25 September 2003, the lower back muscles were tight and the ROM was painful, but remained full.  At the first MEB examination dated 4 November 2003, the CI reported a back injury on 12 December 1999 and pain aggravated by activity and certain motions.  The examination was basically normal other than tenderness.  Spasm was absent and the ROM full as charted below.  A primary care note dated 7 November 2003, for the MEB examination, noted a normal gait and an “essentially normal examination today.”  At the orthopedic addendum to the NARSUM, 12 months prior to separation, the CI reported the onset of back pain in 1999 when he jarred his back after a hard landing in a Bradley (fighting vehicle).  His pain then increased in May 2003 after increased activity following activation and occasional radiation to his right foot was present.  Extension aggravated his pain more than flexion.  On examination, the neurological examination and gait were normal.  He was able to forward bend and touch his toes; hyperextension was painful.  No significant tenderness was present.  The NARSUM was dated 26 April 2004, 8 months prior to separation, referenced an examination dated 22 January 2004, 11 months prior to separation.  It contained information from the above MEB examination and orthopedic addendum.  At the MEB examination 6 months prior to separation, the CI reported ongoing back pain.  Tenderness was present, but not spasm.  The ROM was limited by pain in rotation, but normal otherwise.  The neurological examination was normal.  In a neurology evaluation for headaches on 21 July 2004, the CI was noted to have a normal gait.  At the VA C&P examination performed 8 months after separation, the CI reported longstanding neck and back pain which limited walking to several blocks before he needed to rest.  He used a cane in his right hand.  Flexion was limited to 50 degrees; the remainder of the ROM was normal.  There was no further decrease with repetition.  The gait was slightly antalgic and the neurological examination normal.  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)	MEB ~11 Mo. Pre-Sep	MEB ~06 Mo. Pre-Sep	VA C&P ~8 Mo. Post-Sep	
Flexion (90 Normal)	90	90	50	
Combined (240)	>150	220	200	
Comment	ROM charted exceeds VA normal values; tenderness	Tenderness without spasm.  Limited by pain	Antalgic gait.  Limited by pain	
§4.71a Rating	10%	10%	20%	

The Board directed its attention to its rating recommendation based on the above evidence.  The ROM was typically recorded as either normal or greater than VA normal values until the VA examination which showed rotation limited to 20 degrees.  The VA examination had flexion of 50 degrees, but is an outlier from all prior examinations and no explanation for the reduction in motion, compared to prior examinations, was noted in the C&P.  The probative value of this examination is accordingly reduced.  Incapacitation was not recorded.  The abnormal gait on the VA examination was not specifically attributed to the back and was not associated with either spasm or guarding.  The neurological examination was consistently normal and the presence of an unfitting radiculopathy at separation is not supported.  The Board found no route to a rating higher than the 10% adjudicated by the PEB.  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 back pain condition.  

Chronic Neck Pain Secondary to Degenerative Disc Disease.  There was no indication of a neck injury noted on the pre-accession physical examinations in 2002 and 2003.  The CI was activated on 15 March 2003.  At the first MEB examination dated 4 November 2003, the CI reported a head injury in May 2003, but no reference was made to neck pain.  No annotation for an abnormal finding was made for the head or neck on the examination.  The orthopedic addendum to the NARSUM 12 months prior to separation did not record any problems with the neck.  The first clinical record for the neck pain condition was a primary care visit dated 12 February 2004 which noted a history of neck pain since he struck his head getting out of a military vehicle in May 2003.  An X-ray showed DDD at C5-6 and C6-7.  Some straightening was noted (seen with spasm).  On examination, he had good ROM and a normal neurological examination, but spasm was not documented.  An MRI on 17 February 2004 noted multi-level DDD and DJD.  The CI was seen in neurosurgery on 2 March 2004.  The CI reported intermittent numbness of the left thumb and index finger tips.  Sensation was increased on the left in a C6 distribution.  Motor function was normal.  The NARSUM was dated 26 April 2004, 8 months prior to separation, referenced an examination dated 22 January 2004, 11 months prior to separation.  It noted that the CI had injured his neck in May 2003 when he was getting out of an armored personnel carrier.  He endorsed stiffening and pain since that time.  The neurological examination and gait were normal.  At the MEB examination dated 18 June 2004, 6 months prior to separation, the CI reported arthritis of his neck.  The neurological examination was normal.  No specific findings for the neck were recorded.  In a neurology evaluation for headaches on 21 July 2004, the CI was noted to have a normal gait.  Other than a clinical visit to update the profile, the CI was not seen for the neck condition in a clinical appointment until 21 October 2004 neurosurgery appointment.  The surgeon opined that the neck condition did not pre-exist service and was service related and service aggravated.  The neurosurgeon noted that there was a history of neck pain documented in the CI’s medical records through a good portion of his career and that it was unlikely to have been present at his accession.  (The Board observed that while the neck condition most likely arose following initial enlistment, this is not sufficient to demonstrate that it was caused or permanently aggravated by service.  The question remains whether the condition arose or was aggravated secondary to service or was coincident with his time in the Guard).  On 7 November 2004, 5 weeks prior to separation, the CI was seen in the emergency room for neck pain after he was rear ended at an intersection.  The bumper had slight damage and the car was pushed forward about 2 feet.  The CI did not hit his head, was restrained, and the airbag did not deploy.  He reported tenderness at C2-C3 and tingling of the fingers on the left.  X-rays were negative.  At the VA C&P examination performed 8 months after separation, the CI reported neck pain present for years.  This is not consistent with the history above which indicated that it began in May 2003 after hitting his head.  On examination, he had tenderness to palpation, but spasm was absent.  The ROM was reduced with flexion 30 degrees and a combined ROM of 280 (VA normal values of 45 and 340 degrees, respectively).  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB determined that the neck pain was a pre-existing condition which was not permanently service aggravated.  The Board noted that the CI stated in several clinical encounters that the neck pain began after an injury in May 2003, but the first of these was in February 2004, 9 months after the reported injury and over 3 months after beginning the MEB process.  There was no clinical record of evaluation or treatment proximate to the reported injury.  Moreover, at the first MEB examination and at the orthopedic evaluation for the MEB, neck pathology was not recorded.  Imaging showed both DDD and DJD, indicative of chronic pathology.  Finally, the history given to the VA examiner was that the condition had been present for years.  The Board did not find evidence in the record to overcome the PEB adjudication that the neck condition existed prior to service and was not permanently service aggravated.  The Board concluded therefore that this condition could not be recommended for additional disability rating.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the “migraine without aura,” “depressive disorder, NOS, chronic anger problem,” “mild degenerative arthritis of the left acromioclavicular joint,” “tinnitus,” and “elevated lipids” conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

Headaches were first recorded on the MEB history and physical dated 21 November 2003.  The CI reported daily severe headaches since May 2003.  There were no clinical encounters for migraines documented prior to 27 December 2003 when the CI had an MRI for severe headaches since May 2003.  The commander noted that the CI was treated for migraines and that they seemed to be debilitating when one was present.  A frequency was not recorded.  There were no acute care or emergency room visits for migraine treatment and there is no record of duty impairment other than the commander’s statement.  There were three clinical visits in evidence for the headache condition after the MRI prior to separation.  All were for chronic headache management.  The headache condition was not profiled or judged to fail retention standards.  

The first mental health evaluation was during the MEB process.  The CI was evaluated by psychiatry on 5 February 2004 and determined to have “no psychiatric disorder.”  The CI requested a follow-up and was seen next on 3 March 2004 when he reported anger issues since childhood and that “he thinks that maybe he is depressed…”  He was begun on medications for anger management and mild depression, but thought to meet retention standards.  The final mental health noted was a memorandum for the MEB dated 15 October 2004, 2 months prior to separation, which noted depression since June 2003 and problems stemming from an abusive childhood.  The depression condition was not profiled or judged to fail retention standards.  The commander made no comment on a mental health condition.  

The record shows that the CI broke his clavicle (collar bone) in 1992.  The duty status was not recorded.  At the retention examination on 13 March 2003, he reported no sequelae from this.  He also denied any shoulder problems at the first MEB examination on 4 November 2003.  On 2 April 2004, the CI reported a 3-year history of pain shoulder pain since an injury in the field and was thought to have bursitis of the left shoulder.  An X-ray was remarkable only for the old fracture.  In PT, he had full ROM and signs of impingement with bursitis.  He responded well to PT and the last treatment note dated 4 May 2004 released him to a home exercise program.  The left shoulder condition was not profiled or judged to fail retention standards.  The commander made no specific comment on a shoulder condition.  

There were no clinical records for tinnitus.  Tinnitus was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  

“Elevated lipids” is a laboratory finding and not a physical disability.  Therefore, it is not a ratable condition.  

All were reviewed 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 at separation.  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:  In the matter of the bilateral ankle and knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the 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 neck pain condition, the Board unanimously recommends no change in the PEB adjudication as an existed prior to service condition without permanent service aggravation.  In the matter of the contended “migraine without aura,” “depressive disorder, nos, chronic anger problem,” “mild degenerative arthritis of the left acromioclavicular joint,” “tinnitus,” and “elevated lipids” 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.  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 20140602, 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
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

19 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for, AR20160008649 (PD201402905)

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