RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2015-00760
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Optical Laboratory Specialist, medically separated for “back pain…;” “cervical spondylosis without radiculopathy and right knee pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  
The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20020815	VARD - 20021129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain…	5299-5295	10%	Posterior Midline Herniated Nucleus Pulposus L5-5…	5293-5293	10%	STR	
Cervical Spondylosis and Right Knee Pain	5099-5003	0%	Cervical Spondylosis…	5290	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Back Pain.   According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2001 after a sports injury.  He underwent a discectomy in December 2000 and did well until July 2001 when he developed sudden pain in his low back and radicular pain in his left lower extremity similar to the pain which preceded his surgery.  Conservative therapy did not resolve the pain.  Neurosurgery follow-up determined he was not a surgical candidate.  Initial neuroimaging in October 2001 showed mild degenerative disc changes at L4-L5 and L5-S1.  Repeat neuroimaging showed scar tissue around the S1 nerve root but no new herniations.  The MEB forwarded “chronic low back pain with radiculitis, s/p lumbar discectomy /laminectomy” for PEB adjudication.  

The commander noted he was working in his primary occupation as an optical technician with satisfactory duty performance.  

The 24 May 2002 MEB NARSUM examination, 3 months prior to separation, noted complaints of occasional paresthesisas to the left lower extremity and radiating pain to the right pelvic region.  He denied bowel dysfunction but admitted to occasional urinary post-voiding incontinence with residual urine output of up to an estimated “shot glassful.”  Urology evaluation March 2002 recommended further diagnostic testing but the CI declined.  

Physical examination showed a normal gait, with forward flexion to his shins bilaterally, lateral bend to mid-thigh, and hyperextension to 10 degrees.  Lower extremity (LE) strength of one set of muscles was 4/5 on the left with absent S1 reflex on the same side but otherwise the other LE muscles showed normal strength and there were no other neurological symptoms.  The straight leg raise test (test for herniated disc) was positive on the left at 30 degrees and pain was referred to the lower back on reverse straight leg raise test.  Assessment included status post (s/p) lumbar discectomy/laminectomy and chronic low back pain with radiculitis.

The Board directed attention to its rating recommendation based on the above evidence.  

The PEB rated the back condition 10%, analogously coded 5299-5295 (lumbosacral strain), citing scarring of S1 nerve root and pain on motion.  

The VA rated the back condition 10% analogously coded 5293 (intervertebral disk syndrome), based on the STR, citing painful and limited motion.

The separation date of August 2002 resulted in the PEB rating the low back condition according to the old spine rules. The Board agreed that criteria supporting a rating higher than 10% under the 5295 code are not in evidence (i.e. “with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position”); but debated if a higher rating is supported under other codes in effect at the time of separation.  Under the 5292 code a 20% rating is justified for “moderate” limitation of lumbar motion, but based on the evidence at hand Board members concluded that this degree of limitation was not present.  Likewise, there was no evidence of incapacitating episodes to warrant a minimal rating under the 5295 code (lumbosacral strain).  

The Board finally considered if additional disability was justified for peripheral nerve impairment.  Although there were occasional paresthesisas to the left lower extremity and radiating pain to the right pelvic region and occasional urinary post-voiding incontinence with residual urine output. The MRI showed scarring around the nerve root but no new herniations; and there was slight loss of muscle strength in one LE nerve that could not be linked to any functional deficit or limitation of specific physical requirements.  The Board therefore concludes that additional disability rating for radiculopathy was not justified.

 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 back pain condition.  

Neck Pain.  The PEB combined the cervical spondylosis and right knee pain conditions as a single unfitting condition analogously coded 5003 (arthritis, degenerative) and rated 10%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications. The Board’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for the cervical and spondylosis right knee pain conditions, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to STR and the MEB NARSUM, the CI’s neck and right knee conditions occurred without specific injury or trauma.  

The 24 May 2002 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic neck pain and stiffness with associated paresthesias to both upper extremities.  He reported neurosurgical evaluation but was not determined to be a surgical candidate and was offered a “nerve block” in the future if symptoms persisted.  Neuroimaging revealed multilevel stenosis, especially stenosis at C3-C4 to C6-C7.  There was no evidence of a herniated disc or nerve root impingement.  Physical examination of the cervical spine showed tenderness along the base of the spine at C6-C7 with minimal paravertebral muscle tenderness on range of motion (ROM).  He could forward flex within 2 inches of his chest and extend 30 degrees.  There was no deformity or spasm noted.  Upper extremity strength was 5/5 bilaterally and sensation was intact.  There was a negative cervical compression test on the cervical spine.  

The Board directed attention to its rating recommendation based on the above evidence.  

The PEB rated the neck and right knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  

The VA rated the neck condition 10% coded 5290 (old spine rules, limitation of motion of, cervical), based on the NARSUM exam May 2002, citing slight limitation of motion.  

The NARSUM exam noted the CI could flex his neck within 2 inches of his chest, thereby meeting criteria for slight limitation of motion, rated at 10%, coded 5290.   

The Board finally deliberated if additional disability was justified for peripheral nerve impairment.  Although the CI complained of neck pain and stiffness with paresthesias to both upper extremities, examinations documented no muscle weakness.  There was no evidence in this case of functional deficit or limitation of specific physical requirements due to peripheral nerve impairment.   The Board therefore concludes that additional disability rating for radiculopathy was not justified.

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 cervical spondylosis condition, coded 5290.  

Right Knee Pain.  According to the STR and the MEB NARSUM, the CI’s right knee condition began around March 2002.  He experienced the onset of pain mostly to the lateral side of his knee that was insidious and with no history of trauma.  There was no locking or giving way.  Examination showed full active ROM to 145 degrees with noted genu recurvatum (knee deformity so knees bend backwards) to both knees.  There was no effusion, laxity, evidence of meniscal tear and no joint line tenderness.  There was tenderness to the lateral knee bone.  Neuroimaging of the right knee showed a small suprapatellar joint effusion with a plica tear along the lateral aspect of the patellofemoral joint space that corresponded to his knee pain.  The CI received an L3 profile that included right knee pain and the NARSUM examination noted the symptomatic plica, right knee was medically unacceptable.  The panel determined the right knee was reasonably justified as separately unfitting.

However, there was no evidence of painful motion with functional loss to support a 10% rating for the right knee.  The knee had no ligamentous instability or laxity (5257), no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), and no history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was therefore no VASRD §4.71a route to a rating higher under any applicable code 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 right knee condition.  

BOARD FINDINGS:  In the matter of the back pain condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  

In the matter of the cervical spondylosis condition, the Board unanimously recommends a disability rating of 10%, coded 5290 IAW VASRD §4.71a.  

In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  

There are 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	
Back Pain	5299-5295	10%	
Neck Pain	5290	10%	
Right Knee Pain	5099-5003	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012103, XXXXXXXXXXXXXXXXXXX

Dear:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure