RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04080
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20061121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling Reserve E-4, Chaplain’s Assistant, medically separated for back, bilateral knee, and migraine headache conditions, with a combined disability rating of 10%.

CI CONTENTION:  She requested all conditions be considered. Her 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 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 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 20061026	VARD - 20051110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lower Back Pain	5237	0%	Degenerative Arthritis L5-S1…	5003-5242	20%	20050728	
Bilateral Knee OA	5003	10%	Stress Fracture Of Left Tibia…	5262	20%	20050728	
			Stress Fracture Of Right Tibia…	5262	20%	20050728	
Migraines	8100	---%	Headaches	8100	30%	20050726	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
COMBINED RATING:  10%	COMBINED RATING OF ALL CONDITIONS:  70%	

ANALYSIS SUMMARY:

LBP.  The record shows that the CI attributed both back and bilateral leg pain to a fall in basic training on 16 December 1997.  However, the Line-of-Duty (LOD) determination dated 5 August 2003 only attributed the leg pain to the fall.  In addition, two clinical appointments on 6 and 16 December 1997 recorded left leg pain, but no back pain and no history of a fall.  A different LOD which was dated 15 February 2000 attributed back pain to “crawling in and out of fox holes, shooting, etc.” on 24 April 1999.  At a VA Compensation and Pension (C&P) neurological examination on 30 November 1998, the CI reported mid-back pain which did not radiate.  She moved with ease throughout the examination.  Her neurological examination, range-of-motion (ROM), and gait were normal.  A computed tomography (CT) scan on 10 December 1998 was normal other than mild degenerative changes at the L5-S1 facet joints (where the vertebrae join on the sides) without evidence of disc disease.  A VA orthopedic appointment dated 2 March 2000 noted that the CI attributed her progressive LBP to both the fall in 1997 and falling into a hole in April 1998.  She lived on the third floor of a building without an elevator; she did endorse difficulty with the stairs.  She had a normal gait and minimal difficulty transferring from a sitting to a standing position and then back to sitting.  Some limitation in motion was documented, but not quantified.  Her strength was diminished secondary to pain.  A rehabilitation clinic note dated 21 November 2001 documented that a recent magnetic resonance imaging scan (MRI) done on 1 November 2001, was “essentially normal.”  She was neurologically intact with limited ROM secondary to pain.  The CI had C&P examinations (general, spine, bones) on 17 October 2002.  She was noted to have a normal gait and erect posture.  The ROM was slightly reduced as charted below.  Spasm and tenderness of the spine were noted.  When seen in the ER on 13 March 2003, she was noted to have pain with flexion, but no tenderness (to palpation).  She had C&P examinations repeated on 15 July 2004, 28 months prior to separation.  The CI had an antalgic gait (abnormal secondary to pain).  She used a cane and knee brace and had had surgery on the right knee in April 2004 and on the left in May 2004.  Her ROM was reduced and is charted below.  Her neurological examination was normal.  An X-ray showed some narrowing of the L4-5 disc space.  The next C&P evaluations were on 26 July 2005 (neurological) and 28 July 2005 (unemployability).  The former noted that she was extremely well groomed, but complained of pain on almost every movement and when arising from a chair.  She sighed through most of the examination.  Sensation and reflexes were normal, but she did not give full strength on testing and voiced pain on any attempt to test her muscles.  Her gait appeared normal.  Borderline narrowing at L4-5 was noted on X-ray.  At the unemployability examination, her gait was “steady” and her posture erect (normal).  She had delivered her second child 10 days earlier.  The gait was also noted as antalgic at a different examination the same day.  The narrative summary (NARSUM) was dated 12 September 2005, 14 months prior to separation.  The CI reported radiation of pain to her left leg in a stocking distribution (non-radicular).  Her examination was noted to be difficult as she endorsed pain with any attempt at a physical examination maneuver.  She was tender from her neck to lower back.  The ROM was reduced as charted below.  The motor examination was difficult as any maneuver was painful.  Radicular symptoms were absent and the reflexes normal.  Seven of seven signs of non-organic pain (pain with maneuvers not expected to be painful) were positive.  X-rays were normal.  She reported that she could meet her administrative duty requirements for her military occupational specialty in-garrison.  The examiner noted that she was significantly limited by pain, but had “very few objective findings.”  She was thought to be disqualified due to subjective complaints of pain.  The MEB examination on 25 April 2006, 7 months prior to separation, showed limited ROM as charted below.  The CI was unable to toe or heel walk.  The examiner could not perform a sitting straight leg test (a provocative test for nerve root irritation) although a supine test, which should elicit similar symptoms, was accomplished.  Both evaluate the same pathology.  The CI was also noted to have signs of non-organic pain as had been noted at the NARSUM examination.  At the VA C&P examinations performed on 13 December 2013, 7 years after separation, the CI reported continued pain.  Despite this, she wore high heels and had a normal gait.  Signs of non-organic pain were present.  The neurological examination was normal and provocative testing for nerve root irritation negative.  

The Board directed attention to its rating recommendation based on the above evidence.  The record shows that the CI had no active duty points from 1999-2001, 38 days in 2002, and then was activated for one day on 21 November 2006, the day of separation.  The second VA C&P, on 17 October 2002, was after both the fall off the obstacle course and one into the foxhole to which the CI attributed her symptoms.  It shows some limitation in motion, but a normal gait.  Another examination, 7 years after separation, shows an essentially normal examination with flexion limited to 10 degrees less than full.  She had a normal gait with high heels, an observation not consistent with a permanent disability featuring significant LBP.  The Board considered the evidence proximate to separation.  Both the NARSUM, 14 months prior to separation, and the DD Form 2808, Report of Medical Examination, 7 months prior to separation, showed a flexion limited to 30 degrees; however, both also noted that there were signs of non-organic causes of pain reducing the validity of these measurements.  A CT scan had shown minimal degenerative changes which would not lead to the level of disability shown by the CI.  An MRI was noted to be essentially normal.  A sensory examination showed a loss in a stocking distribution, a finding not consistent with a radicular (spine) cause.  The initial PEB rated the back at 0% observing the findings of non-organic pain on multiple examinations.  The adjudication was upheld after rebuttal, on the FPEB, and again on review of the rebuttal of the FPEB adjudication.  After review of the totality of evidence, the Board finds the examinations proximate to separation are not probative in the assessment of the actual disability and that there is insufficient cause to change the PEB adjudication.  The evidence does not support the presence of an unfitting radiculopathy at separation.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

Bilateral Knee Osteoarthritis.  The CI first reported left leg pain on 6 December 1997 (no history of a fall was recorded).  She was then seen a week later for the same complaint (again no history of a fall was recorded).  X-rays of both lower legs, on 24 January 1998, noted that the CI had fallen 35 feet (date not recorded).  The x-rays were normal.  The CI was then seen on 9 March 1998 for stress fractures and noted to be tender over both shin bones, mid-shaft.  She was again seen on 26 April 1998 for persistent pain and referred for a bone scan.  The Board found no record that this was accomplished.  The next record in evidence is an orthopedic note dated 22 March 1999 which documented that the CI fell about 35 feet on 6 December 1997.  She was noted to have tenderness over the entire length of both shin bones and slightly reduced flexion of the knees, but her sensory and motor examination was normal.  As noted above, the CI was able to take multiple PFTs, including the run, following the accident.  The neurological C&P examination on 30 November 1998 documented that the CI had a normal gait and moved with ease.  At another C&P examination the next day, she reported ongoing knee and ankle pain which was aggravated by walking fast or running.  The examiner recorded that a bone scan on 30 April 1998 had been positive for minimal shin splints (no pathology was recorded for the knees).  She had full ROM and provocative testing for a meniscal tear was negative.  The knee was stable, but some pain was noted with movement of the left kneecap.  Her gait was noted to be stable on tandem walk.  She was next evaluated on 17 October 2002, again with multiple C&P examinations, and complained of bilateral knee pain and intermittent leg pain.  Her gait was noted to be stable and the ROM of both knees reduced in flexion to 130 (right) and 132 (left) with pain at the end of motion.  X-rays of the knees and legs were normal.  Tenderness over the shins was noted bilaterally.  The record then falls silent until 14 January 2004 when an MRI shows a tear of the right posterior horn of the medial meniscus (a cartilage cushion in the knee).  The CI had another set of C&P examinations on 15 July 2004.  This examination was done within months of bilateral knee surgeries.  These records are not in evidence.  Her ROM was limited (see ROM chart below) and her gait antalgic.  The menisci and ligaments (for stability) could not be evaluated secondary to pain.  X-rays on 16 July 2004 were normal for the left knee and showed a benign bone island (a density on X-ray) on the right.  An orthopedic note dated 18 August 2004 documented that the CI had arthroscopic surgery of each knee, the right in April 2004 and the left in May 2004.  It noted that she had reported pain since a fall in 1997 despite rehabilitation.  When seen in PT on 23 September 2004, it was recorded that she showed an abnormal gait at times but a normal gait at other times.  Her examination was limited as “everything hurts pt. to sever [sic] degree.”  A follow-up PT note dated 9 November 2004 documented that the CI “demonstrates increased ROM in all when distracted from pain” referring to her back, neck, and knee pain.  In PT on 9 December 2004, the therapist wrote “pt cont to have poor tolerance to therex [therapeutic exercises] which is major limitation to pt’s progress complicated by questionable follow-up with HEPs (home exercise program).”  The CI was evaluated in orthopedics on 11 January 2005 and noted that she was doing well since her surgery other than decreased ROM.  When seen in the emergency room on 5 May 2005 for bilateral leg pain, she reported recurrent pain after running out of her pain medications.  She denied new trauma.  On examination, she had bilateral knee and leg pain on palpation of the muscles, but no localized tenderness and the ROM was full.  The CI had C&P examinations again on 28 July 2005, 16 months prior to separation.  At an unemployability examination, she reported that she fell 25 feet in December 1997 and injured her back and knees.  Her posture was erect and gait steady.  However, on the joints examination, her gait was noted to be antalgic.  Flexion was reduced bilaterally as recorded below.  On the left knee, signs of meniscal irritation were absent and the knee stable.  On the right, testing for meniscal irritation could not be done secondary to pain.  The NARSUM was dated 12 September 2005.  The CI reported that she had meniscal tears debrided in both knees and that her right knee had improved, but that the left continued to bother her.  She had an antalgic gait and her examination was “difficult due to the fact that she has pain with any attempt at any physical examination maneuver.”  As noted above, 7/7 signs of non-organic pain were present.  The right knee was not tender; neither knee had an effusion; the knees were stable and testing for meniscal irritation was negative.  The left knee showed mild joint line tenderness on the inside of the knee (medial aspect).  The examiner noted that she was significantly limited by pain, but had “very few objective findings.”  She was thought to be disqualified due to subjective complaints of pain.  An X-ray of the right knee on 12 September 2005 was unremarkable other than a probable bipartite patella (a problem when the kneecap fails to fuse together in childhood).  The NARSUM noted minimal changes of degenerative change (not unusual for her age).  At the MEB examination on 25 May 2006, the examination of the lower extremities was recorded as normal other than scars.  She was again seen in the emergency room on 12 September 2006 complaining of left knee pain after having hit it with her bag.  There was a question of moderate tenderness on motion, but no swelling.  At the VA C&P examination performed on 24 July 2010, 44 months after separation, the CI reported progressive pain, stiffness, and weakness.  On examination, the gait was normal.  Crepitus, an abnormal sensation or sound associated with degeneration, was present.  The ROM was reduced as charted below.  Motion was painful bilaterally.  Neither instability nor meniscal signs were present.  X-rays were unremarkable other than the previously noted bony island.  The final record in evidence for the lower leg and knee conditions is the VA C&P dated 13 December 2013, 7 years after separation and accomplished by an orthopedic surgeon.  On examination, the ROM was full and painless.  The knee was stable and signs of meniscal irritation absent.  Her shins were tender bilaterally, but the examiner noted signs of “overreaction/magnification.”  She was wearing high heels and had a normal gait.  Review of the profiles in evidence does not show that the CI was on a profile for a lower leg condition until 16 May 1999.  This profile was for bilateral “tendoachilles” (a condition other than shin splints or a knee condition).  The only profile in evidence for the knee condition was the final profile dated 4 October 2005 which noted bilateral knee pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB initially determined that the knee condition was EPTS and not PSA as she was separated in “apparent good health.”  The Board noted that the incident cited by the CI as causative for the knee pain and later recorded in an LOD dated 5 August 2003, almost 6 years after the event, is not found recorded in records of sick slip visits dated 6 and 16 December 1997, the two dates recorded for the fall.  The history of a fall was first noted on an X-ray report over a month later.  The CI rebutted the adjudication, but it was upheld by the USAPDA.  The CI then appealed to the FPEB which noted that there was limited cooperation by the CI on the examination and that 7/7 signs of non-organic pain were present.  The condition was still considered EPTS, but PSA was conceded.  The CI again rebutted this adjudication.  The FPEB adjudication was upheld on review, but the case forwarded to the USAPDA for final review and adjudication.  The condition was then noted to have minimal degenerative changes on X-rays with no mechanical limitation in motion.  She was rated for two joints using the 5003 (degenerative arthritis) code.

The Board considered the evidence.  While the CI attributed her knee pain to a fall in basic training and was issued an LOD for this (6 years after the reported event), the contemporaneous records in evidence do not support this.  In fact, the CI successfully completed several 2-mile runs following this fall with times close to what she had recorded weeks prior and actually better than a time recorded a month prior to the stated fall.  She underwent surgery of both knees over 6 years later.  A VA orthopedic surgeon attributed the knee issues to the fall in 1997.  This physician was at a location different from that where the surgery was done and, as already noted, the contemporaneous records available for review do not support this history.  The examination closest to separation was compromised by the inability to obtain an adequate examination (as noted above in the back discussion) and by the presence of 7/7 signs of non-organic pain.  However, the VA C&P examinations which bracket separation showed stable knees without meniscal signs.  The ROM was not ratable on any measurement outside the immediate post-operative period.  The CI reported painful motion; this supports a 10% rating for both knees using the 5003 code (degenerative arthritis) IAW VASRD §4.59 (painful motion).  The Board considered if each knee was separately unfitting, but did not find reasonable justification to overturn the PEB adjudication that the knees were unfitting as a combined condition, and ratable as such within the proper application of the VASRD.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic bilateral knee osteoarthritis condition.

Migraines.  The CI indicated a history of severe or frequent headaches on her pre-accession history.  There were records in evidence that she was treated for a headache condition while on active duty.  The headache condition was not profiled or implicated by her commander.  The NARSUM noted that the headaches were EPTS as documented in a 2 April 1998 note which recorded that the CI had been diagnosed with migraines prior to entry into the Army.  The evidence does not support a change in the PEB adjudication that the headaches were EPTS without PSA.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination for the migraine condition.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

BOARD FINDINGS: In the matter of the 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 adjudication.  In the matter of the migraine headache condition, the Board unanimously recommends no change in the PEB adjudication.  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 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SA MR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

JUL 1 4 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20160004521 (PD201404080)

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
( ) OVA