RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04253
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Counter Intelligence Agent, medically separated for “chronic low back pain,” “chronic left knee pain” and “chronic left hip 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 – 20041020	VARD - 20050217	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	DDD of the Lumbar Spine…	5242	20%	20050106	
Chronic Left Knee Pain	5099-5003	0%	Lateral Tibial band Syndrome…	5260	10%		
Chronic Left Hip Pain	5019	0%	Greater Trochanteric Bursitis…	5252	0%		
Migraine with Aura	Not Unfitting	Migraines	8100	30%		
Neck Pain   		DDD…Cervical Spine	5242	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained injuries to his left knee, foot, and forearm prior to service in motor vehicle accidents (MVA) in October 2002.  All of these required surgery and were declared prior to accession.  Other than surgical scars, no abnormality was recorded on the accession physical.  The back examination was also recorded as normal.  As documented in a physical therapy (PT) note dated 2 March 2004, during AIT (advanced infantry training) the CI had the insidious onset of left knee and then left hip pain with subsequent development of low back pain (LBP).  On examination, the range of motion (ROM) of the back was normal and he was thought to have dysfunction of the sacro-iliac joints (SIJs), the joints between the lower spine and the pelvis.  His pain had been refractory to medications including steroid injections and physical therapy.  On 15 June 2004, decreased disc space at L5-S1 was noted; this is consistent with degenerative disc disease (DDD).  In orthopedics on 16 June 2004, he reported non-reproducible numbness of the left foot which was not anatomical in distribution.  On examination, forward flexion was full and the neurological examination was normal.  A slight antalgic (abnormal secondary to pain) gait was present.  The CI was determined to no longer meet retention standards and was referred for MEB.  The MEB forwarded LBP with radiation secondary to L5-S1 disk protrusion for PEB adjudication.  In family practice examination 2 weeks later on 30 June 2004, the CI reported the onset of LBP following the aforementioned MVA (not consistent with the history above).  The ROM was limited, but the motor and reflex examinations were normal.  In physical medicine on 28 July 2004, the CI reported the onset of left knee pain after he tripped and fell in AIT in November 2002 with the development of left hip pain and LBP.  He walked with a limp due to the hip pain.  Flexion was noted to be “markedly limited.”  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 3 August 2004, 5 months prior to separation, the CI reported ongoing LBP with numbness and tingling of the left leg.  On examination he was noted to have paraspinal tenderness and a negative neurological examination.  Provocative nerve root testing was negative.  A neurological examination for the MEB on 6 August 2004, 6 months prior to separation, noted there was paraspinal spasm.  The motor examination was normal other than “give way” weakness due to pain (decreased effort due to pain).  Sensation was reduced in a left L5-S1 distribution.  The reflexes were normal.  Provocative testing for nerve root irritation was positive on the left.  An MRI on 10 August 2004 showed a small disc protrusion at L4-5 without canal or neuroforaminal narrowing (no cord or nerve root impingement).  Formal ROM was obtained in PT on 18 August 2004, and is charted below.  The MEB NARSUM examination on 14 September 2004, 5 months prior to separation, noted that the CI stepped into a hole while running in October 2002 injuring his left knee.  He developed left hip pain several weeks later and then a few months after that the LBP began.  He denied trauma other than heavy lifting.  On examination, he used a cane for walking.  The actual findings mirrored those of the above MEB, neurological, and PT examinations.  In family practice on 24 September 2004, the CI had flexion limited to 25 degrees.  Paraspinal tenderness was present, but spasm was not documented.  Provocative testing for nerve root irritation was negative.  The CI presented to the emergency room for a flare of his LBP on 4 November 2004.  On examination, tenderness was present and a provocative test for nerve root irritation was positive on the left; however, the neurological examination was normal.  

At the VA Compensation and Pension (C&P) evaluation, performed on 6 January 2005, 3 weeks before separation, the CI reported that his left knee, left hip, and back pain all began during a run when he stepped into a pothole at 0300.  He denied incapacitation.  On examination, spasm was present but tenderness absent.  The ROM was limited by pain as charted below.  Reflexes were normal and provocative testing for nerve root irritation negative.  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)	PT ~11 Mo. Pre-Sep	Ortho ~8 Mo. Pre-Sep	PT ~6 Mo. Pre-Sep	FP ~4 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (90 Normal)	WNL	Fingers to toes	60	25	60	
Combined (240)	WNL		185	---	180	
Comment		Normal Neurological Examination	Limited by pain	No explanation for the decrease in flexion	Limited by pain	
§4.71a Rating	0%	0%	20%	40%	20%	
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition at 10%, coded 5237 (lumbosacral strain).  The VA rated the DDD lumbar spine with radiculopathy condition 20% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 3 weeks prior to separation, citing the limited ROM.  The flexion measured in family practice in September 2004 supports a 40% rating, but is an outlier from the other examinations and not consistent with the physical findings.  In addition, there was no explanation in the note for the significant reduction in motion.  Accordingly, the probative value of this examination is reduced.  The PT and C&P examinations proximate to separation both support a 20% rating and were accomplished with a goniometer.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the back condition, coded 5237.  The Board did not find evidence that a separately unfitting radiculopathy was present at separation.  

Chronic Left Knee Pain.  According to STR and the MEB NARSUM, the CI had surgical repair of the anterior cruciate ligament (ACL) of the left knee on 13 April 1983.  This was declared by the CI prior to accession and the entrance physical examination only noted the presence of surgical scars.  As noted above, the left knee pain began in 2002 and was refractory to medications, PT, and duty limitations.  X-rays on 15 June 2004 were normal.  In orthopedics on 16 June 2004, 8 months prior to separation, the CI reported global left knee pain.  On examination, the knee was stable and without signs of meniscal (a cartilage cushion in the knee) irritation.  An X-ray was noted to show signs of sclerosis (increased density of the bone), but no evidence of cartilage degeneration (normal joint space).  No diagnosis other than left knee pain was rendered.  An MEB was recommended.  The MEB forwarded chronic left knee pain for PEB adjudication.  In physical medicine on 28 July 2004, the CI reported that he tripped and fell in November 2002 with the immediate onset of left knee pain.  It was on both sides of the knee and aggravated by walking.  On examination, he limped secondary to the left hip pain.  The outside of the knee was tender, but there was no swelling or locking.  He was thought to have chronic left knee pain.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 3 August 2004, 5 months prior to separation, the CI reported ongoing left knee pain since October 2002 after stepping into a hole while running.  On examination he was tender to palpation, but no other pathology was recorded.  The MEB NARSUM examination on 14 September 2004, 5 months prior to separation, noted that the CI stepped into a hole while running in October 2002 injuring his left knee.  On examination, he used a cane for walking.  The knee showed tenderness to palpation, but the examination was otherwise unremarkable.  At the VA C&P evaluation, performed on 6 January 2005, 3 weeks before separation, the CI reported that his left knee pain dated to the fall in 2002, but also reported the surgery in the 1980’s after a motorcycle accident.  On examination, flexion was reduced to 135 degrees with tightness (140 is normal), but pain free.  The gait was antalgic, but his cane was carried in his right hand and the cause of the abnormal gait was not specified.  Movement of the kneecap produced painful crepitus (an audible or sensible sensation of grinding).  The knee was otherwise unremarkable.  An X-ray was suspicious for early signs of cartilage degeneration, but no effusion (fluid) or joint space narrowing was present.  He was diagnosed with lateral iliotibial band syndrome although it was noted that the lateral iliotibial band was not tender.  The Board noted that this condition was not previously diagnosed in the records in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left knee pain condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing no loss of joint motion or evidence of joint instability.  The VA rated the left knee lateral tibial band syndrome condition 10%, coded 5260 (limitation of flexion) based on the VA C&P examination 3 weeks before separation, even though it was noted that the criteria for a 10% rating were not specifically met.  The Board considered the findings.  The limitation in motion was not compensable under any code.  There was no evidence for a meniscal injury, instability, or of painful motion.  The Board found no route to a rating higher than the 0% adjudicated by the PEB.  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 adjudication for the chronic left knee pain condition.  

Chronic Left Hip Pain Due to Trochanteric Bursitis.  According to STR and the MEB NARSUM, the CI’s hip condition began several weeks after he injured his knee while running in the fall of 2002.  He was diagnosed with greater trochanteric bursitis (inflammation of a fluid fill sac [bursa] between the hip joint and the muscles over it).  He was treated with medications, PT, and duty limitations without resolution of the pain.  X-rays on 15 June 2004 were normal.  In orthopedics on 16 June 2004, 8 months prior to separation, the CI reported pain directly over the left greater trochanter (part of the femur which is part of the hip).  On examination, the hip was otherwise unremarkable except for an antalgic gait.  An X-ray was noted to be normal.  He was diagnosed with greater trochanteric bursitis.  An MEB was recommended.  The MEB forwarded chronic left hip pain due to trochanteric bursitis for PEB adjudication.  In physical medicine on 28 July 2004, the CI reported that he tripped and fell in November 2002 with the subsequent development of left hip pain.  On examination, he limped secondary to the left hip pain and the greater trochanter was tender to palpation.  He was diagnosed with left trochanteric bursitis.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 3 August 2004, 5 months prior to separation, the CI reported ongoing left hip pain.  On examination he was tender to palpation and the ROM was noted to be limited due to pain, but no other pathology was recorded.  The MEB NARSUM examination on 14 September 2004, 5 months prior to separation, noted that the CI stepped into a hole while running in October 2002 injuring his left knee.  On examination, he used a cane for walking.  The hip ROM was normal.  Abduction (legs out) and internal rotation increased his pain.  The greater trochanter was tender.  The examination was otherwise unremarkable.  At the VA C&P evaluation, performed on 6 January 2005, 3 weeks before separation, the CI reported that his left hip pain began several weeks after fall in 2002.  The greater trochanter was no longer tender to palpation.  The ROM was limited as charted below, but without pain.  He was noted to be currently asymptomatic from the greater trochanteric bursitis.  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)	PT ~11 Mo. Pre-Sep	MEB ~5 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (125 Normal)	WNL	Normal	110	
Extension (20)	WNL	Normal	30	
External Rotation (45)	WNL	Normal	40	
Abduction (0-45)	WNL	Normal	40	
Adduction (45)	WNL	Normal	#	
Comment	---	Pain with motion	Pain free motion	
§4.71a Rating	0%	0%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left hip pain due to trochanteric bursitis condition 0%, coded 5019 (bursitis), noting no significant loss of motion.  The VA also rated the chronic left greater trochanteric bursitis condition at 0% coded 5252 (limitation of flexion of the thigh), based on the VA C&P examination 3 weeks prior to separation, noting that the limitation in motion was non-compensable and without pain.  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 adjudication for the chronic left hip pain condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the migraine with aura and neck pain secondary to [a] herniated C5-C6 disk were not unfitting.  Neither condition was profiled or judged to fail retention standards.  The migraines were specifically noted by the treating neurologist to meet retention standards.  However, headaches were implicated in the commander’s statement.  The clinical encounters in evidence for the migraine condition were for medication management.  There were no emergency rooms visits nor periods of quarters in evidence other than the commander’s statement.  It noted that the CI had missed at least 2 days over the prior 2 months in the statement prepared 6 months prior to separation.  There was no performance-based evidence from the record that either condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either contended condition and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic LBP condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the left knee pain and left hip pain conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine with aura and neck pain secondary to herniated C5-6 disk conditions, 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic LBP Onset Following Knee Injury in Oct 02	5237	20%	
without Loss of Joint Motion	5099-5003	0%	
Chronic Left Hip Pain Due to Trochanteric Bursitis	5019	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX AR20160014213 (PD201404253)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA