RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03351
BRANCH OF SERVICE:  AIR FORCE 		SEPARATION DATE:  20020729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Vehicle Maintenance Control and Analysis, medically separated for “bilateral knee and low back conditions,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  His conditions should have been rated separately and he should have received a higher rating.  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 - 20020409	VARD - 20031110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5295	10%	Low Back Spasms	5237	10%	20030822	
			Upper Back Spasms Associated with Low Back Spasms	5299-5237	NSC		
Chronic Patellofemoral Syndrome	5257	10%	Chondromalacia Patella, Left Knee	5099-5014	10%		
			Chondromalacia Patella, Right Knee	5099-5014	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:   

Low Back Pain (LBP).  The service treatment record (STR) indicated the CI was seen for LBP on 29 February 2000 that revealed a normal gait and full range of motion (ROM) of the back.  That same encounter noted “…had upper back pain and neck pain resolved, now LBP every day.”  Lumbar X-rays were reported as “unremarkable.”  Despite aggressive physical therapy the CI continued with painful symptoms and eventually was referred to a Medical Evaluation Board.  At the narrative summary (NARSUM) examination performed on 12 December 2001 (8 months prior to separation), the CI’s chief complaint was “LBP.”  His physical examination (PE) revealed full ROM of the entire spine.  Although not specifically identified to any anatomic spinal area, tenderness was present and documented as “He [the CI] has paraspinus muscular tenderness.”  His prognosis was noted as “stable.”  At the VA general medical Compensation and Pension examination performed on 22 August 2003 (13 months after separation), the CI reported a daily sharp 4/10 back pain.  He endorsed 10/10 painful flare-ups occurring every 2-3 months each with single day duration.  He uses no ambulating assist devices and wore no bracing implements.  His comprehensive PE was completely normal.  His diagnosis was listed as “back pain without mechanical musculoskeletal abnormalities identified.”  

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB rated the back condition at 10% under code 5295 (lumbosacral strain; with characteristic pain on motion).  The VA also rated the low back condition at 10% utilizing code 5237 (lumbosacral strain) under current VASRD guidelines citing the presence of localized tenderness without resulting in an abnormal gait or abnormal spinal contour.  Board members agreed that absent compensable ROM parameters coupled with normal PE findings excepting paraspinus muscle tenderness from either side of service separation would not render a higher impairment rating than the PEB’s current 10%.  After due deliberation, considering all of the evidence and mindful of the 2002 VASRD, the Board concluded that there was insufficient cause to recommend a change in the PEB’s adjudication for the low back pain condition. 

Chronic Patellofemoral Syndrome (PFS).  Although the PEBs primary diagnosis of PFS was not right/left sided identified, the STR and NARSUM clearly noted a bilateral condition.  On 9 October 2001 the CI received steroid injections to both knees with removal of fluid (effusion) from the left knee.   Orthopedic follow-up examination on 22 October 2001 revealed a normal examination excepting tenderness at the superior aspect of the patella with no identification of unilateral or bilateral involvement.  At the NARSUM examination the CI had a normal gait, and full ROM of both knees.  There was no evidence of joint instability, joint pain, meniscal tear, or local erythema.  “He [The CI] has pain elicited with patellar pressure and patellar grind.”  At the VA examination, the CI stated that he does not have daily knee pain, but painful flare-ups occur weekly with each episode lasting for an hour to a full day.  His PE was completely normal and X-rays were reported as “normal.”  The examiner also noted ‘knees were stable and non-tender on all maneuvers.  The final diagnosis was listed as bilateral chondromalacia patella. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB bundled the bilateral knee condition at 10% under VASRD code 5257 (knee; other impairment).  The VA separately rated each knee at 10% analogously coded under VASRD 5014 (osteomalcia) citing painful or limited motion.  The Board first considered whether each knee condition remained separately unfitting, having decoupled them from the combined PEB adjudication.  Although the majority of clinical encounters contained in the case file appeared equivocal in both subjective physical complaints as well as objective physical findings in relation to both knees, it was the recorded evidence of a small joint effusion reflected that the left knee was associated with more pathology than the right knee.  Board members considered the absence of an apparent right-sided effusion and raised the question of whether the right knee was reasonably justified as separately unfitting near the time of Service separation.  All parameters considered, excepting the left-sided effusion, the attendant physical exam and radiologic attributes were nearly identical to both knees.  Board members 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 duties within his military specialty; but, it is also reasonable to surmise that it was the combination of pathology from both knees that rendered him unfit.  While there was no evidence of compensable limitation of motion, the Board’s consensus was that the PEB’s 10% “bundled” rating was supported by painful motion (§4.59) as closely related to the presence of patellar grind and crepitus noted in pre-separation examinations.  Absent objective evidence of ankylosis, instability, frequent locking, or surgical intervention, there was no VASRD route to a higher impairment rating.  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 final rating decision, but a change of code was appropriate as to reflect a bilateral condition.  The PEB’s chosen code of 5257 is strictly a unilateral code and thus not appropriate in this case.   

BOARD FINDINGS:  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 bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB’s rating, but a code change to 5099-5003.  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, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain 	5295	10%	
Chronic Bilateral Patellofemoral Syndrome	5099-5003	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140702, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03351.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

Sincerely,

Attachment:
1.  Directive
2.  Record of Proceedings 

cc:
SAF/MRBR