RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04260
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20040707

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Military Police, medically separated for “chronic low back pain [LBP],” “bilateral retro-patellar pain syndrome” and “mild right ankle instability, rated 10%, 0% and 0%, respectively, with combined disability rating of 10%.  

CI CONTENTION:  "Please consider all conditions.” The CI also submitted a one page letter used by the Board in its recommendation.  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 - 20040505	VARD - 20051004	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5239	10%	Low Back Pain…	5237	40%	20050505	
Bilateral Retropatellar Pain Syndrome	5099-5003	0%	Left Knee Arthralgia	5299-5257	10%		
			Right Knee Arthralgia	5299-5257	10%		
Mild Right Ankle Instability	5099-5003	0%	Right Ankle Instability	5271	10%		
PTSD And Alcohol Dependence	Not Unfitting	PTSD	9411	30%	20050810	
Alcohol Dependence		No VA Entry	
Tinea Versicolor		No VA Entry	
Mild Right Carpal Tunnel Syndrome		No VA Entry	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

Chronic LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was activated in early 2003 and then deployed.  While in-theater, she was treated for sand fly bites and then developed fatigue, diffuse tingling, and LBP.  A summary of her care, dated 29 July 2003, noted that she had full range of motion (ROM) of the back and normal reflexes without evidence of nerve root irritation.  She was returned to her home station due to numerous complaints and seen in neurology on 3 September 2003.  The neurological examination of the lower extremities was normal other than decreased pin prick of the left lower extremity (LLE) with retained position and vibratory sensation.  The gait was normal.  An MRI on 6 September 2003, showed some slippage (spondylolisthesis) of L5 on S1 with bilateral narrowing of the nerve root outlet (foramina).  Multi-level degenerative disc disease (DDD) and degenerative joint disease (DJD) was noted without cord impingement.  The CI was determined to fail retention standards and referred for MEB.  The MEB forwarded chronic [LBP] secondary to DDD for PEB adjudication.  A bone scan on 27 October 2003, showed increased uptake in the sacro-iliac joint, the joint between the pelvis and lower back, right greater than left.  At the MEB examination dated 23 October 2003, the CI reported a “back” problem with minor problems in the past.  She noted this was the primary reason for the MEB.  On examination, she was noted to have back pain with a normal neurological evaluation.  Pelvis and left hip X-rays were normal on 14 November 2003.  Nerve conduction velocities done for paresthesias (abnormal sensations) of the right lower extremity (RLE) were normal on 2 December 2003.  Formal ROM measurements were obtained in physical therapy the next day; however, these were for the lumbar spine rather than the combined thoraco lumbar ROM values used for rating purposes by the VASRD.  The probative value is therefore reduced.  The CI was seen in orthopedics for the MEB on 24 December 2004, 6 months prior to separation.  She reported diffuse numbness and tingling in her arms and legs (not in a radicular distribution).  On examination, she could forward flex to within 1 foot of the ground (over 60 degrees).  The remainder of the ROM evaluation was noted to be reduced without further detail.  The motor examination was normal.  Diffuse lumbar spine tenderness was present.  The MEB NARSUM examination on 17 March 2004, 4 months prior to separation, noted complaints of back pain for several years which was aggravated while deployed.  It was worse with activity and had not improved with physical therapy (PT).  On examination, she was noted to have a normal gait, strength, and reflexes.  Provocative testing for nerve root irritation was negative.  Tenderness was present over the lumbar spine.  At the VA Compensation and Pension (C&P) evaluation, performed on 5 May 2005, 10 months after separation, the CI reported that her LBP began in the later 1990’s after a gradual onset.  She endorsed incapacitation, the last episode lasting 2 days several months previously.  On examination, provocative testing for nerve root irritation was positive at 10-15 degrees.  The ROM was limited, but apparently stopped at the onset of pain.  Tenderness was present over the lumbar spine, but spasm was not documented.  No comment was made on the gait or the neurological examination.  A second VA C&P for the back was accomplished on 23 April 2007, 34 months after separation and outside the normal 12 month window assigned higher probative value for rating at separation.  It was considered due to the wide variation in ROM values obtained proximate to separation.  The CI was noted to have a normal gait without the use of assistive devices.  No interval intervention (surgery, injections, etc.) was recorded.  Her muscles were noted to be tight, but neither spasm nor tenderness was documented.  Sensation was recorded as reduced in the left L5-S1 distribution, but the motor and reflex examinations were normal.  Flexion was normal, but the other measurements reduced to 10 degrees each (from a normal 30 degrees).  An MRI report from 18 August 2006 was noted as showing the degenerative changes and spondylolisthesis.  However, there was no evidence for cord or nerve root (neural) impingement.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition at 10%, coded 5239 (spondylolisthesis), citing tenderness.  The VA rated the back condition 40% coded 5237 (lumbosacral strain), based on the VA C&P examination 10 months after separation, citing limitation in motion.  The Board considered the evidence.  The initial evaluation noted that the CI had normal ROM.  Four months later, the lumbar (only) ROM was significantly reduced, but no reason to account for the reduction was recorded.  A few weeks later, in orthopedics, the flexion was near normal although the other measurements were decreased.  The VA examination supports a 40% rating, but it appears that the measurements were stopped at the onset of pain rather than to the limit from pain.  There was no indication as to why the limitation in motion was so great; spasm was not recorded.  This examination was also incomplete in that neither the gait nor neurological examination was recorded.  The probative value for the examination is accordingly reduced.  The Board noted that the initial and orthopedic evaluations, unlike the formal measurements, were not accomplished specifically for rating purposes.  These examinations are also consistent with the pathology in evidence and the lack of a gradual onset of pain.  The second VA C&P examination is outside the normal window for probative value.  However, it supports the initial evaluation and the orthopedic ROM evaluations.  It also records a normal gait and neurological examination which are consistent with the pathology in evidence.  The Board also noted that the second C&P documented a second MRI which did not show neural impingement, consistent with the majority of the examinations.  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 low back pain condition.  

Bilateral Retropatellar Pain Syndrome.  According to the STR, the MEB NARSUM, and VA C&P examination, the CI’s bilateral knee pain condition began gradually in the 1990’s without specific trauma.  The Board found no treatment records proximate to separation until the CI was in the MEB process.  The MEB forwarded bilateral intermittent pain consistent with retropatellar pain syndrome (RPPS) for PEB adjudication.  At the MEB examination dated 23 October 2003, the CI reported knee trouble throughout her life.  On examination, she was noted to have knee pain with a normal neurological evaluation.  X-rays on 23 December 2003 showed small bilateral joint effusions (fluid) and mild degenerative changes.  In orthopedics on 24 December 2003, the CI reported her bilateral knee pain was aggravated by running.  She denied specific trauma.  No effusion was present and the ROM was full.  Instability was not documented.  The MEB NARSUM examination on 17 March 2004, noted no specific complaints for the knees.  On examination, she was noted to have a normal gait, strength, and reflexes.  No comment was made on stability.  In orthopedics on 25 October 2004, 4 months after separation, she was noted to have stable knees with flexion limited to 135 degrees (140 is normal).  Crepitus (an audible or sensible sensation of grating) was present, but painful motion not documented.  Medial joint line tenderness was present bilaterally.  No effusion was present.  At the VA C&P evaluation, performed on 5 May 2005, 10 months after separation, the CI reported her knee pain began in the later 1990’s after a gradual onset.  She frequent flares and occasional use of a cane.  On examination, deep knee bending was full but pain was present (unclear at what point).  Flexion was limited to 100 degrees by pain.  Extension was normal.  The Board noted that a full deep knee bend is past 100 degrees and could not reconcile these two statements.  Regardless, the limitation in motion is not compensable, so this did not impact the rating decision.  The examiner also noted bilateral crepitus and mild anterior laxity.  X-rays were ordered, but are not in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral retropatellar pain syndrome condition 0%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated each knee 10% for pain (arthralgia), coded 5299-5257 (other impairment of the knee) citing pain with motion and instability based on the VA C&P examination.  The Board considered the evidence.  Limitation in motion was documented on some examinations but not all.  Painful motion was also not consistently present.  Meniscal injury was not present.  The examinations closest to separation were accomplished in orthopedics.  One supports mild limitation in motion, the other was normal.  Neither showed instability nor pain with motion.  An effusion was not present on examination (although a mild effusion was seen on X-ray 7 months prior to separation).  The preponderance of evidence supports a 10% rating for involvement of 2 or more major joints absent incapacitation without limitation in motion.  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 bilateral retropatellar pain syndrome condition, coded 5003.  

Right Ankle Instability without Significant Joint Laxity.  According to STR and the MEB NARSUM the CI also was evaluated for right ankle pain after being entered into the MEB process.  An undated MRI showed a defect of the cartilage lining of one of the ankle bones and a tear of a ligament.  At the MEB examination the CI reported that she injured her right ankle in October 2002.  On examination, she was noted to have bilateral ankle pain.  A civilian orthopedist evaluated the CI on 5 November 2003.  Tenderness with near full motion was recorded.  Some pain with motion was present and a small amount of crepitus was present.  The ankle was stable.  It was anticipated that she might require future arthroscopy due to a lack of response to treatment.  In orthopedics on 24 December 2003, the CI reported that multiple ankle injuries.  She was noted to have 5 degrees of dorsiflexion bilaterally and 10 degrees of plantar flexion bilaterally.  However, she had normal motor function in plantar and dorsi-flexion.  Instability was not recorded in the examination although it was listed as a diagnosis.  It is not clear if this was in error or not.  The MEB NARSUM examination on 17 March 2004, 4 months prior to separation, recorded no specific complaints for the ankles.  On examination, she was noted to have a normal gait, strength, and reflexes.  No comment was made on stability.  In orthopedics on 25 October 2004, 4 months after separation, she was noted to have a history of right ankle sprains since high school, most recently in October 2002.  She reported that it locked and gave out.  On examination, dorsiflexion was 25 degrees and plantar flexion was 50 degrees (VA normal values are respectively 20 and 45).  Crepitus and tenderness to palpation were present.  The ankle was stable.  At the VA C&P evaluation, performed on 5 May 2005, 10 months after separation, the CI was not specifically evaluated for the right ankle condition.  The 7 September 2005 examination, 14 months after separation, noted that the CI reported right ankle pain after she twisted her ankle while running in 2003.  She reported that an MRI showed a torn ligament, bone chip, and a talus defect.  She reported instability and weekly incapacitation for 1 hour.  She reported intermittent use of a cane.  On examination, there was no effusion, bony abnormality, or tenderness present.  Laxity was noted.  Dorsiflexion was limited bilaterally (0 degrees right and 5 degrees left, VA normal 20) with normal plantar flexion at 45 degrees.  An X-ray was normal on 21 March 2005.  No specific limitation from the ankle was cited.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 0%, coded 5099-5003, citing slight and intermittent pain (USAPDA pain policy language).  The VA rated the right ankle instability condition 10% coded 5271, (limited motion of the ankle), based on the VA C&P examinations 14 months after separation, citing moderate limitation in motion.  The Board considered the evidence.  The NARSUM noted normal function and a normal gait, implying functional ROM, and recorded no specific complaints for the ankle.  Four months after separation, an orthopedic evaluation documented a stable ankle with a ROM which exceeded VA normal values.  It was noted that there was a history of multiple ankle sprains beginning in high school.  There was a wide variance in findings between the examinations.  However, the 2 examinations with bracket separation by 4 months, document a normal gait, ROM, and stable ankle between them.  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 right ankle condition at separation.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended alcohol dependence, PTSD [post-traumatic stress disorder], tinea versicolor, and mild right carpal tunnel syndrome conditions were not unfitting.  The alcohol dependence and PTSD conditions were issued an S2 profile.  The commander’s statement noted that she had PTSD without ascribing duty limitations to it.  None were judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions and so no additional disability ratings are recommended.  
BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral RPPS condition, the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the right ankle instability condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended alcohol dependence, PTSD, tinea versicolor, and mild right carpal tunnel syndrome conditions, the Board unanimously recommends no change from the PEB determinations 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 Due to Multilevel DDD	5239	10%	
Bilateral RPPS	5003	10%	
Mild Right Ankle Instability	5099-5003	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

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, AR20160018323 (PD201404260)

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