RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03557
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040604

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

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 based upon a 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 - Dated 20040329	VARD - 20040617   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Low Back Pain	5237	10%	Thoracolumbar Strain	5237	40%	20040520	
Chronic Left Hip Pain	5019	0%	Left Hip Trochanteric Bursitis	5019 	10%		
Left Knee Pain	5099-5003	0%	Left Knee Retropatellar Pain Syndrome	5024	0%		
Right Knee Pain	Not Unfitting	Right Knee Pain	5257	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Myofascial Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in December 2002 after a battalion run.  The CI denied any specific injury or trauma.  Radiographic studies conducted in September and December 2003 showed an overall normal spine with some scoliosis (abnormal curvature) noted.  There was no surgical indication.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded myofascial pain syndrome for PEB adjudication.  

During the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 10 October 2003, 8 months prior to separation, the CI reported lower back pain with numbness and tingling in lower legs and toes.  Physical examination showed tenderness of the paravertebral muscles of the low back while the CI reported pain with examination maneuvers not expected to elicit pain based on the known pathology.  At the time of the orthopedic clinic appointment on 11 March 2003, the CI complained of mid back pain, particularly with prolonged sitting, walking and lifting.  Orthopedic and Physical Therapy (PT) treatments provided no lasting relief.  Physical examination revealed increased lumbar lordosis with tenderness to palpation in paraspinal muscles.  Similar to a previous examination, provocative maneuvers for signs of radiculopathy or radiating pain were negative.  

The MEB NARSUM examination on 31 December 2003, 5 months prior to separation, noted CI complaints of low grade pain in the high lumbar area that did not radiate.  Physical examination showed an antalgic gait using a cane.  Neurologic examination showed strength of 4/5 (normal 5/5) in all muscles of the lower extremities secondary to pain.  Lower extremity sensation and reflex testing was normal.  The CI could walk on her heels, but could not walk on her toes secondary to hip pain.  Back examination showed tenderness with negative provocative testing for radiculopathy.  

The physician cited a MEB-PT evaluation dated 16 October 2003, 8 months prior to separation, which showed a mildly antalgic gait with use of a cane, and inability to achieve a straight posture.  There was a moderate increase in lumbar lordosis with hip flexion apparent contractures.  There was decreased back range of motion (ROM) with left groin pain limiting all motion as charted below.  The examiner stated “inconsistent starting position with the instruction to "stand up as straight as you can" resulted in differences with bubble goniometry flexion measurements” and flexion measurements were repeated six times (normal three repetitions).  

At the time of the physical medicine appointment for electro-diagnostic testing on 14 November 2003, 7 months prior to separation, the CI reported back and left hip pain of 6-8/10.  Examination showed a markedly antalgic gait due to the left lower extremity.  There was difficulty walking on heels/toes due to pain and poor stance.  There was increased lordosis of the back and tenderness to palpation.  Straight leg raise testing for radicular symptoms was negative while other testing for hip/back pain (FABER and modified OBER) were positive.  Back ROM was 60% or 80% of normal.  Neurologic examination was normal for sensory and reflex testing; there was marked diffuse bilateral lower extremity breakaway weakness due to pain.  The specialist determined that electrodiagnostic testing was “not indicated as very low clinical suspicion for radiculopathy based on clinical presentation and CT scan.”  Diagnosis was chronic mechanical and myofascial low back pain.  The physician also diagnosed “left worse than right hip pain with greater trochanteric bursitis, probable girdle enthesonopathies/tendonopathies.”  

At the 20 May 2004 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported daily tightness and spasms without any radicular symptoms.  Physical examination showed tenderness to palpation with no muscular spasm.  A diagnostic study performed on 13 May 2005 showed moderate abnormal spinal curvature of the lower thoracic and upper lumbar spine.  Thoracolumbar ROM was “markedly limited” as charted below.  Motor, sensory, and reflex testing of the lower extremities was normal.  

At the time of the VA new patient clinical note, dated 27 May 2005, 12 months after separation, the CI complained of back pain with spasms.  Examination documented a normal gait with back muscle tightness and decreased flexibility in the back.  At the time of the physical medicine appointment on 14 June 2005, 12 months after separation, the CI reported continued pain.  The examiner recorded scoliosis, an antalgic gait, tenderness to palpation, full sensation, and “grossly decreased” ROM by 30%.  There was overall 4/5 motor weakness with no focal finding.  

The ROM examinations 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 ~ 15 Mo. Pre-Sep	PT ~14 Mo. Pre-Sep	MEB-PT ~8 Mo. Pre-Sep	PM ~7 Mo. Pre-Sep	NARSUM ~6 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (90 Normal)	40	60	30	60% / 80%	Cited MEB-PT ROMs; tenderness	30	
Combined (240)	unk	unk	105			70	
Comment	Extension 20 degrees	Mild scoliosis; extension 20 degrees	Painful motion, antalgic gait: see text	Tenderness; increased lordosis		Painful motion; repetition increases pain with no change in ROM	
§4.71a Rating	20%	20%	40%	20%	40%	40%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial low back condition 10% coded 5237 (lumbosacral strain), citing tenderness and “range of motion restriction due to pain alone,” likely applying AR 635-40, paragraph B-29 in effect at the time.  The VA rated the thoracolumbar strain condition 40%, also coded 5237, based on the VA C&P examination 15 days before separation, citing forward flexion equal to 30 degrees.  

The VA examination was closest to and prior to separation and aligned with NARSUM and PT evidence of thoracolumbar forward flexion limited to 30 degrees.  The remote primary care clinic and orthopedic examinations, were greater than one year prior to separation, were incomplete and were comparatively remote from separation to carry significant probative value.  The physical medicine evaluation and remote clinic notes did not include VASRD compliant (§4.46 - accurate measurement) ROMs.  The VASRD accounts for separately rating the spine and the hip conditions, and there was no pathway for deducting from the back ROM-based rating based on hip pathology.  The Board majority adjudged that the highest probative value examinations met the 40% rating criteria for “forward flexion of the thoracolumbar spine 30 degrees or less.”  

After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 40% for the myofascial low back pain condition, coded 5237.  

Chronic Left Hip Pain Condition.  According to the STR and the MEB NARSUM, the CI’s left hip pain condition began in April 2002 after ruck marching in basic training.  A bone scan showed increased uptake in the left hip area.  A follow-up bone scan as well as other diagnostic imaging (MRI) reported in July 2003 was normal.  Orthopedic evaluation in October 2003 noted hip pain led to evacuation from Korea and that hip pain limited activities.  Examination showed full active painless ROM of the left hip with equivocal testing for apprehension.  Despite treatment, the left hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic left hip trochanteric bursitis” for PEB adjudication.  

At the time of the physical medicine appointment the CI reported back and left hip pain of 6-8/10.  Examination is detailed above (painful hip motion and antalgic gait) with left hip ROMs charted below.  

The MEB NARSUM examination on 31 December 2003, 6 months prior to separation, noted CI complaints of chronic left hip pain.  As noted above, physical examination showed an antalgic gait using a cane; slight weakness in all muscles of the lower extremities secondary to pain, and inability to walk on her toes secondary to hip pain.  There was tenderness to palpation over the left greater trochanter and over the quadriceps tendon.  A MEB PT exam dated 16 October 2003, 8 months prior to separation, showed a mildly antalgic gait with use of a cane, inability to achieve a straight posture, and “hip flexion apparent contractures.”  There was left groin pain with all back ROM.  

At the 20 May 2004 C&P evaluation, performed 1 month before separation, the CI reported daily left hip pain worsened with weight bearing.  Physical examination showed tenderness to palpation and pain limited ROM as charted below.  

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Hip (Thigh) ROM
(Degrees)	PCC ~15 Mo. Pre-Sep	Ortho ~9 Mo. Pre-Sep	Ortho ~8 Mo. Pre-Sep	PM ~7 Mo. Pre-Sep	MEB-PT ~8 Mo. Pre-Sep
NARSUM ~6 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (125 Normal)	“WNL”	50	“FAROM w/o Pain”	90	Left groin pain with all back ROM; antalgic gait; cane; slight weakness 2nd to pain; inability to walk on toes 2nd to hip pain	90	
Extension (20)	--	20				10	
External Rotation (45)	“WNL”	40				10	
Abduction (0-45)	--	45		50		10	
Adduction (45)	--	40		50		10	
Comment	Painful motion	Negative apprehension and impingement tests		Painful motion		Painful motion	
§4.71a Rating	10%	0%	0%	10%	10%	20% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5019 code (Bursitis), citing pain due to trochanteric bursitis without significant loss of joint motion.  The VA assigned a 10% rating using the 5019 code based on the VA C&P examination 1 month before separation, citing decreased ROM.  

The Board considered the probative value of the multiple examinations in evidence.  Only the VA examination documented limitation of motion which supported a rating under the diagnostic codes for limitation of abduction or rotation (5253).  There was no fracture, non-union, or malunion of the femur to support consideration under the respective codes for hip impairment related to long bone conditions (5255), and service examinations did not document compensable limitations of hip motion.  However, there was sufficient objective evidence of painful motion on the PM, PT and NARSUM examinations supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the VA.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left hip pain condition, coded 5019.  

Left Knee Pain Condition.  According to the STR and MEB NARSUM, the CI’s left knee condition began in June 2002 with no history of injury.  Radiographic studies in 2003 showed normal alignment.  At the time of the primary care clinic appointment on 7 March 2003, the CI complained of ongoing knee pain.  On examination the CI had full ROM without instability.  Despite treatment, the left knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “retropatellar pain syndrome with left greater than right” for PEB adjudication.  

During the MEB examination the CI reported occasional swelling and the sensation of the knee giving way and popping.  Physical examination showed a stable knee with a slow gait and use of a cane.  At the time of the physical medicine appointment the CI reported left knee pain of 7/10.  The left knee was tender with diffuse breakaway weakness in both legs secondary to pain.  The MEB NARSUM examination noted the complaint of left knee pain.  Physical examination revealed bilateral knees with full ROM and no effusion, laxity, or instability.  There was positive patellar grind on the left knee.  The CI walked with an altered gait and utilized a cane.  

At the 20 May 2004 C&P evaluation the CI reported daily left knee pain under the patellar, occasional swelling, and rare instability.  Physical examination showed left knee pain limited flexion to 90 degrees and normal extension, with increased pain on repetition.  There was no crepitus, effusion, or instability.  At the time of the physical therapy appointment on 27 May 2005, the examiner noted a normal gait with decreased flexibility of the legs.  There was no crepitus, swelling, redness or warmth of the left knee.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, analogously coded 5003, (Degenerative Arthritis), citing full ROM without instability.  The VA rated the left knee condition 0%, coded 5024, (Tenosynovitis), citing full range of painless motion without objective evidence of functional limitation or instability.  

The Board noted that the VA examination was the single outlier indicating pain limited motion, and there were inconsistencies within the examination regarding DeLuca and the presence or absence of instability.  The Board adjudged that the NARSUM examination had the highest probative value for rating at separation.  The preponderance of the evidence did not support painful motion with functional loss at a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise 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), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (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).  No additional functional limitation was evidenced by the examinations.  Therefore, the Board concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  After due deliberation, and 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.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right knee pain was not unfitting.  The right knee pain was profiled, but not implicated in the commander’s statement and was not judged to fail retention standards.  The physical examination, at the primary care clinic appointment on 7 March 2003, showed full ROM without instability.  A radiographic study in December 2003 showed normal alignment.  The MEB NARSUM, showed no instability with full ROM, as did the pre-separation VA examination.  There was no performance based evidence from the record that this condition 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 contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the myofascial low back pain condition, the Board majority recommends a disability rating of 40%, coded 5237 IAW VASRD §4.71a.  The single voter for dissent did not elect to submit a minority opinion.  In the matter of the chronic left hip pain condition, the Board unanimously recommends a disability rating of 10%, coded 5019 IAW VASRD §4.71a.  In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee 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 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Low Back Pain	5237	40%	
Chronic Left Hip Pain	5019	10%	
Left Knee Pain	5099-5003	0%	
COMBINED	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140729, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160017516 (PD201403557)

1.  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 reject the Board’s majority recommendation and hereby deny the individual’s application.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.  

2.  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.

CF: 
(  ) DoD PDBR
(  ) DVA