RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00056
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040721

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Infantryman, medically separated for “chronic pain, left knee” and “mechanical lower back pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  CI contended the VA raised his rating from 30% to 80%.  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 - 20040607	VARD - 20050315	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee	5099-5003	10%	Residuals, Depression Fracture Tibial Plateau, Left Knee, with Osteoarthritis	5010	10%	20041115	
Mechanical Lower Back Pain	5299-5237	10%	Low Back Strain with Mild Degenerative Disc Disease Lumbar Spine	5243	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Pain, Left Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in January 2004 after falling 30 feet during a training exercise.  Radiographic studies showed a depressed left knee tibial plateau fracture.  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 “lateral tibial plateau depression fracture, left knee” for PEB adjudication.  At the time of the physical therapy clinic appointment on 9 February 2004, the examiner recorded knee pain as intermittent, occasional and sharp.  The examiner noted the CI using Percocet for pain relief.  On examination the active range of motion (ROM) was flexion to 130 degrees (normal 140) and normal extension.  The MEB NARSUM, 6 May 2004, noted left knee pain with a ROM of 0-130 degrees.  At the MEB NARSUM examination, the CI described his knee pain as slight and constant and was taking Motrin to relieve symptoms.  The MEB physical examination noted no significant joint line tenderness and no antalgic gait.  There was no crepitus or grinding of the patella.  The CI had a negative McMurray (test for knee cartilage damage) and a negative Drawer test (test for instability).  At the 15 November 2004 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported experiencing locking, buckling and instability of his left knee.  The physical examination showed a negative Lachman’s, a negative Drawer and a negative McMurray’s bilaterally.  The examiner noted no effusion or deformity.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain, left knee condition 10%, coded 5099-5003 (arthritis, degenerative), citing pain rated as slight/constant.  The VA rated the chronic pain, left knee condition 10% coded 5010 (arthritis, due to trauma), based on the VA C&P examination 4 months after separation, citing range of motion of left knee 0-110 degrees to include locking, buckling and instability.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  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).  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 pain, left knee condition.  

Lower Back Pain.  According to STR and the MEB NARSUM, the CI’s low back pain condition began in January 2004 after falling 30 feet during a training exercise.  Radiographic studies were normal.  There were no degenerative changes, no spondylolisthesis or spondylolysis with a normal lordosis of the lumbar spine.  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 “mechanical lower back pain” for PEB adjudication.  

At the time of the physical therapy clinic appointment on 17 March 2004, the CI rated his back pain 2/10.  The examiner noted swelling was still present in the CI’s back described as tenderness and tightness. The thoracolumbar ROM was noted as flexion to 85 degrees (normal 90), extension to 30 degrees (normal), and a combined ROM of 230 degrees (normal 240).  At the MEB NARSUM examination, the CI reported burning lower pain was exacerbated when wearing his ruck sack and lifting but denied any numbness or weakness.  The CI denied any radiating pain to his lower extremity.  The MEB physical examination noted forward flexion to the level of his ankles, extension to 30 degrees, later bending and rotation to 40 degrees bilaterally.  There was mild lumbosacral tenderness to palpation.  Radiculopathy testing was negative.  There was a positive Patrick’s test (for flexion, abduction, and external rotation) resulting in mild back pain.  At the 15 November 2004 C&P evaluation, performed 4 months after separation, the CI reported that his number one complaint was his back condition.  The CI disclosed that he had not had back surgery and did not use any devices for his back.  The physical examination showed mild decreased lumbar lordosis and a slight increase in thoracic kyphosis.  Painful motion was not present through all planes of motion.  Radiculopathy testing was negative.  The Rom was noted as forward flexion to 110 degrees (normal 90), extension to 20 degrees (normal 30), and a combined ROM of 230 degrees (normal 240).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the mechanical lower back pain condition 10%, coded 5299-5237 (lumbar spine strain), citing the US Army Physical Disability Agency (USAPDA) pain policy and no neurologic abnormality or significant limitation of motion.  The VA rated the mechanical lower back pain condition 0% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 4 months after separation, citing a forward flexion of 60 degrees but not greater than 85 degrees.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT, NARSUM and C&P examinations.  There no was evidence of muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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 mechanical lower back pain condition.  

BOARD FINDINGS:  In the matter of the chronic pain, left knee and mechanical lower back pain… conditions and IAW VASRD §4.71a, 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 20150120, 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 
XXXXXXXXXXXXXXXXXX, AR20160018838 (PD201500056)

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