RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03782
BRANCH OF SERVICE: Army	SEPARATION DATE:  20090806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Cavalry Scout, medically separated for “chronic left knee pain” and “lumbar intervertebral disc syndrome,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the Board 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 – Dated 20090421	VARD - 20091021	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	S/P Lateral Meniscectomy w/Arthritis, Left Knee	5010-5260	10%	20091021	
Lumbar Intervertebral Disc Syndrome	5243	10%	Degenerative Disc Disease, Lumbar Spine	5237	10%	20091021	
Cataract of Left Eye	Not Unfitting	Exotropia, Amblyopia, And Pseudophakia, of the Left Eye	6066-6027	NSC	20091022	
Hyperlipidemia	Not Unfitting	No VA Entry				
Left Shoulder Pain	Not Unfitting	Bursitis, Tendonitis, Left Shoulder	5019	10%	20091021	
COMBINED RATING:  20%	COMBINED RATING:  30%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  In October 2007, the CI experienced a “painful pop” in his left knee while running.  Magnetic resonance imaging performed on 29 December 2007 revealed evidence of patellar (kneecap) chondromalacia.  On 15 February 2008, he underwent a surgical debridement of the left patella.  Post-operatively, mobility improved, but pain persisted despite physical therapy.  He was permanently profiled in November 2008 with a diagnosis of left knee chondromalacia of patella status post chondroplasty (surgical procedure).  At the narrative summary (NARSUM) examination on 12 February 2009 (6 months prior to separation), the CI reported continued left knee pain with varying pain intensities worsened with standing from a sitting position, climbing stairs, prolonged standing, or walking more than a mile.  Additionally, he endorsed knee pain flare-ups 2-3 times per week with pain extending into his left foot and toes.  His physical examination (PE) revealed left knee tenderness and painful motion.  There was no mention of joint instability, crepitus, or effusion.  The diagnosis remained unchanged.  

At the VA Compensation and Pension (C&P) examination on 7 January 2009 (7 months prior to separation), the CI endorsed left knee pain aggravated by exercise, prolonged standing, and running.  Alleviating factors were rest, medication, and stretching.  His physical examination (PE) was completely normal.  The diagnosis was left knee chondromalacia with normal examination and strength.  Another VA C&P examination performed on 21 October 2009 (2 months after separation) noted left knee flexion of 125 degrees.  The diagnosis on this VA examination was arthritis, left knee.  

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.

Left Knee ROM
(Degrees)	VA C&P ~7 Mo. Pre-Sep	MEB ~6 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
Flexion (140 Normal)	140	130	125	
Extension (0 Normal)	0	-	-	
Comment	-	painful motion 	painful motion 	
§4.71a Rating	0%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under analogous 5003 code (degenerative arthritis).  Using an analogous dual code 5010-5259 (traumatic arthritis-leg; flexion limitation), the VA also assigned a 10% rating citing painful motion.  The Board first agreed that in the presence of non-compensable ROM, the PEB’s 10% rating was supported under the 5003 coding pathway by evidence of painful motion (§4.59) or the presence of arthritis within the knee joint (§4.71a).  Absent instability or worsening evidence of limited flexion, members agreed that there were no available alternative joint or analogous coding options which were applicable and or advantageous to the CI’s current 10% 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’s adjudication for the left knee condition.

Low Back Pain (LBP).  The service treatment record (STR) indicated that the CI had a long-standing history of LBP which worsened over the timeframe of 2007-2009.  Radiographic work-up revealed degenerative changes within the lumbar spine, disc herniation at L3-L4, and disc protrusion at L5-S1.  Although he received epidural steroid injections, his mainstay of treatment consisted of chiropractic manipulations.  The permanent profile listed his diagnosis as chronic LBP due to degenerative disc disease (DDD) with herniation at L3-L4 and L5-S1.  At the NARSUM examination the CI reported 3-4/10 LBP at rest aggravated to 8/10 with prolonged sitting or standing.  He endorsed the inability to bend, kneel, squat, run, or do 3-5 second rushes.  His pain improved with stretching, exercise, heat and medications.  His PE revealed lumbosacral tenderness and painful limited ROM.  The diagnosis was chronic LBP due to DDD with herniated discs.  At the VA C&P examination on 21 October 2009 (2 months after separation), the CI endorsed back soreness and pain with occasional left leg pain and altered sensation.  The VA PE revealed decreased thoracolumbar ROM with tenderness and spasms across the lumbar spine.  Pain was increased with repetitive use, but no additional range loss was noted.  There was diminished sensation over the outside and back of his left leg.  The diagnosis was lumbar disc disease with left radiculitis.  

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 ~6 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
Flexion (90 Normal)	85	65	
Extension (30)	30	20	
R Lat Flexion (30)	30	20	
L Lat Flexion (30)	30	20	
R Rotation (30)	30	20	
L Rotation (30)	30	20	
Combined (240)	235	165	
Comment	tenderness; painful motion	tenderness; spasm	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  Although the PEB and VA titled the unfitting back condition slightly differently, they both utilized similar VASRD codes of 5243 (intervertebral disc syndrome) and 5237 (lumbosacral strain) citing limited ROM.  Board members first considered examination probative value (PV) and agreed that the VA examination (closer to separation) be assigned a greater degree of PV in this case.  However, despite differing criteria parameters being fulfilled, members also acknowledged that either examination as charted above would not support a rating greater than the PEB’s current 10%.  Members additionally considered if any lower extremity symptomology warranted an additional Service disability rating; but, all members agreed that the requisite link of any neuropathic symptoms with functional impairment were not in evidence.  Any pain component of a neuropathy or radiculopathy is subsumed under the general spine rating as specified in §4.71a.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a rating of 10% for the LBP condition was appropriately recommended in this case.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left cataract, hyperlipidemia and left shoulder pain were indeed 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.  The conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  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.  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’s fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  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 LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left cataract, hyperlipidemia and left shoulder condition, the Board unanimously recommends no change from the PEB’s 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 20140807, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160009345 (PD201403782)

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