RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00219
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E6, Cargo Specialist, medically separated for “low back pain” and “chronic left knee pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contended for his back, bilateral knees and “several other conditions” as related to Persian Gulf and Iraq deployments.  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 - 20040823	VARD - 20060505	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5243	10%	Spondylosis with No Radiculopathy	5237	10%	20060201	
Chronic Left Knee Pain	5003	0%	Left Knee Osteoarthritis	5257-5003	10%	20060201	
Eczema, Bilateral Legs	Not Unfitting	Leg Rash	7899-7806	NSC	20060201	
Headaches	Not Unfitting	Migraine Headaches	8100	NSC	20060201	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) condition began in April 2003 while deployed without specific incident.  The CI reported LBP with occasional radiation down right lower extremity (RLE).  Lumbar spine X-rays were normal and magnetic resonance imaging on 20 February 2004 showed a “small” right herniated disc at L5-S1, with “minimal” mass effect on the right S1 nerve root.  No surgery was recommended.  Despite treatment, LBP with occasional RLE radicular symptoms continued.  The MEB forwarded “chronic left knee pain s/p arthroscopy with osteoarthritis” for PEB adjudication.  The commander’s statement noted that “at no time has the physical impairment limited his [the CI] duties.”  The commander noted that the CI’s supervisor and the commander himself witnessed the CI’s performance in field positions and stated that “there is no doubt in my mind that {the CI} can physically perform anytime, anyplace, or under any conditions.”  The permanent profile dated 28 April 2004 listed chronic right knee pain (presumed to be a clerical error that lists right knee instead of left knee which was noted by NARSUM and MEB and adjudicated by the PEB) and chronic LBP.  The profile indicated the CI was able to perform alternate physical fitness events of walk or bike.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated June 2004, 5 months prior to separation, the CI reported recurrent LBP with numbness and tingling in the RLE.  Physical examination showed normal spinal contours with tenderness to palpation (TTP) in the lumbar region and bilateral sacroiliac joints.  Lower extremity strength, sensation, and reflexes were normal and straight leg raise (SLR) testing to elicit radicular symptoms was negative.  At the MEB NARSUM examination on 18 June 2004, 5 months prior to separation, the CI reported back injury with the same symptoms noted above.  Physical examination findings of the MEB DD Form 2808 examination above were cited.  Physical therapy measured range of motion on 4 June 2004 was flexion of 90 degrees (normal 90) and combined ROM of 240 degrees (normal 240) and all measurements were repeated three times without change.  The MEB NARSUM examiner indicated that the CI failed retention standards due to the chronic LBP.

At the 1 February 2006 VA Compensation and Pension (C&P) evaluation, performed 14 months after separation, the CI reported intermittent LBP with RLE numbness, aggravated by activity and relieved by over the counter anti-inflammatory medication.  The CI reported that at the time of pain he could function with medication and the condition did not cause any incapacitation.  Physical examination showed normal posture and gait and normal spinal curvatures.  There was no tenderness or muscle spasm.  The ROM was flexion of 90 degrees and combined ROM of 240 degrees and there was no additional limitation of ROM with repetitive use.  The examiner noted that there were no signs of intervertebral disc syndrome with chronic and permanent nerve root impairment.  Lower extremity strength, sensation, and reflexes were normal.  There was no evidence of radiating pain with movement and SLR testing was negative.  Lumbar spine MRI on 14 May 2005 showed degenerative changes of the discs and spine.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5243 (intervertebral disc syndrome), citing TTP with full flexion.  The VA also rated the low back condition 10% coded 5237 (lumbosacral strain), based on the VA C&P examination 14 months after separation.  There was evidence of “localized tenderness” with a normal gait and spinal contours noted at the MEB exams to support a 10% rating.  There was no evidence of limited motion or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour for a higher rating.  Although the CI had intervertebral disc disease, there was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for IVDS.  The CI reported occasional radiating pain to the RLE extremity with numbness and tingling.  Radiating pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates)” and there was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability 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 low back condition.  

Chronic Left Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic left knee pain condition began in March 2003 after a twisting injury.  Knee X-rays showed degenerative changes.  Left knee magnetic resonance imaging on 20 January 2004 showed mild arthritis, a small joint effusion and a medial meniscus tear.  Arthroscopic surgery was performed on 17 March 2004.  Following the surgery no further impact activities were recommended.  The MEB forwarded “chronic left knee pain s/p arthroscopy with osteoarthritis” for PEB adjudication.  

At the MEB examination, physical examination showed TTP and mild patellar grind noted.  There was no evidence of instability or meniscal pathology.  The MEB NARSUM examination noted complaints of knee injury.  Physical examination findings of the DD Form 2808 examination above were cited.  Physical therapy measured ROM on 4 June 2004 was 0 degrees extension (normal 0) and 130 degrees flexion (normal 140).  The MEB NARSUM examiner indicated that the CI failed retention standards due to the chronic left knee pain.

At the 1 February 2006 VA Compensation and Pension (C&P) evaluation, performed 14 months after separation, the CI reported bilateral knee arthritis.  The CI reported intermittent pain, swelling, weakness, and giving way of the knee.  The pain was aggravated by activity and relieved by rest.  The CI reported that at the time of pain he could function with medication.  The examination noted the CI lost work two times per week due to the condition, but also noted there was no functional impairment.  Physical examination showed a normal gait without use of assistive device for ambulation.  There was no effusion, tenderness, abnormal guarding or movement or weakness of the left knee.  Left knee ROM was 0 degrees extension and 140 degrees flexion, with no additional limitation after repetitive use.  There was no evidence of instability or meniscal pathology.  Left knee X-rays showed degenerative arthritis changes.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded 5003 (degenerative arthritis.), citing arthritis of a single major joint.  The VA rated the knee condition 10% coded 5257-5003 (other knee impairment-degenerative arthritis), based on the VA C&P examination 14 months after separation, citing painful or limited motion of a major joint.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was evidence of painful motion/pain upon use with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was also applicable in this case, but also provides a 10% rating.  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) to support a higher rating under the respective codes.  There was also 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 is therefore no VASRD §4.71a route to a rating higher than the 10% 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 recommends a disability rating of 10% for the left knee condition, coded 5099-5003.  

Contended PEB Conditions:  Eczema, Bilateral Legs, and Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or 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 chronic left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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	
Low Back Pain	5243	10%	
Chronic Left Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150311, 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

03 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002565 (PD201500219)

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