RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01123
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20071130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, aviation mechanic, medically separated for “low back pain” and “right knee pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  The CI’s 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 - 20070927	VARD - 20080131	
Condition	Code	Rating	Condition	Code	Rating		
Patellofemoral Syndrome	5299-5003	10%	Status Post Right Knee ACL Tear with Surgical Repair	5260	10%		
Lumbar Degenerative Disk Disease, Herniated Nucleus Pulposus	5243	10%	Degenerative Joint Disease with Broad Base Bulge at L5-S1 and Left Side Radiculopathy	5242	20%		
Right Knee Pain S/P ACL Repair X 2	Cat II Related to Patellofemoral Syndrome	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Patellofemoral Syndrome According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s patellofemoral syndrome condition began in March 2006 after attempting to jump over a ditch when the ground gave way and he fell and heard a loud pop.  The CI underwent arthroscopic surgery in June of 2006 and a second ACL repair several months later.  In March 2007, the CI had removal of hardware for right knee pain.  Despite surgical and medical treat the right knee pain could.  A magnetic resonance imaging (MRI) study of the right knee performed on 10 May 2006 showed bone contusion, mild edema involving the lateral femoral condyle and medial tibial plateau, an anterior cruciate ligament tear and a small to moderate joint effusion without Baker’s cyst.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated August 2007, 3 months prior to separation, the CI reported constant right knee pain.  The CI reported that he had difficulties going up and down ladders and that it was impossible to kneel.  He stated that the pain was severe when bending or going up and down stairs, constant stiffness and minimal swelling.  Physical examination demonstrated fatigue and lack of endurance with movement of the area.  There was not any instability, locking, subluxation or inflammation.  There was tenderness over the patellar tendon and inferior patella.  The CI had significant grinding in extension and flexion, 2+, under the patella and wore a hinged brace when ambulating.  Range of motion (ROM) demonstrated flexion to 130 degrees with pain and extension to 130 degrees.  Stability testing was negative. 

The MEB NARSUM examination on 2 August 2007, 3 months prior to separation, noted complaints of persistent right anterior knee pain, grinding and loss of motion which worsened with exertion or running.  Physical examination showed a midline, well healed scar.  There was intermittent mild effusion to the area.  Anterior drawer sign was slightly positive, however other relevant maneuvers were negative.  ROM was noted as “3/0/135 degrees.”  

At the 1 August 2007 VA Compensation and Pension (C&P) evaluation, performed 3months before separation, the CI reported right knee pain, constant stiffness, and severe pain when bending or going up and down stairs.  He reported minimal swelling, fatigue, and lack of endurance.  He avoided yardwork, football, running and could not walk more than a mile and a half.  The CI stated that he did not lift more than 10 – 15 pounds because of his knee.  The CI was noted to wear a hinged brace when walking.  Physical examination showed patellar tenderness to palpation and 2+ grinding with flexion and extension.  ROM was flexion 0 -130 degrees with pain from 110 – 130 degrees and extension was 130 – 0 degrees.  The examiner noted that repetition would likely be additionally limited with weight bearing due to pain.  The examiner observed the CI modified his squat, going down on the left knee to avoid bending the right knee more than 90 degrees.  Stability testing was negative.  

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right knee condition 10%, coded 5299-5003 (arthritis, degenerative).  The VA also rated the right knee condition 10% coded 5260 (Leg, limitation of flexion), based on the VA C&P examination 2 months after separation, citing range of motion is 0 to 130 degrees with painful motion and tenderness to touch.  

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.  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 is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the patellofemoral syndrome condition.  

Contended PEB Condition, Related Category 2 Diagnosis:  Right Knee Pain Status Post (S/P) Anterior Cruciate Ligament (ACL) Repair X 2.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was appropriately subsumed in the right patellofemoral syndrome condition and did not warrant a separate rating.  The CI’s right knee pain began and persisted after the fall and after surgeries.  According with VASRD §4.14, Avoidance of pyramiding, the Board cannot recommend it for additional rating.

Low Back Pain According to STR and the MEB NARSUM, the CI’s low back pain condition began in September 2006 after suffered from an antalgic and altered gait subsequent to knee problems.  Radiographic findings of the lumbar spine demonstrated mild degenerative changes of the lower lumbar spine with mild intervertebral disk narrowing at L5-S1.  The examiner also noted radiographic findings dated 4/30/07 showed “lumbar degenerative joint disease/degenerative disc disease with slight impingement of the thecal sac, centrally, and right of midline, and also slight impingement of the right S1 nerve root from possible eccentric bulging of the disk annulus, or a small disk herniation.”  

The MEB NARSUM examination on 2 August 2007, 3 months prior to separation, noted complaints of low back pain with radicular symptoms for over six months.  The CI stated that his back discomfort began around the time that he underwent his second ACL repair.    The CI reported that his “back discomfort” exacerbations of 6/10 with sneezing, coughing and movement.  Physical examination showed ROM was limited in forward flexion at approximately 70 degrees (normal 90) with fingertips 14 inches from the floor, extension decreased by approximately 50 % (15 degrees), side-bending left was decreased by approximately 60% (25 degrees), side-bending right was decreased by 50% (15 degrees), and bilateral rotation was decreased by 50% (15 degrees); combined motion of 150 degrees (normal 240).  The examiner noted credible pain behaviors in all ROMs.  Straight leg raise on the left was positive. There was thoracolumbar tenderness to palpation and paravertebral musculature spasm.  

At the 1 August 2007 VA C&P evaluation, performed 3 months before separation, the CI reported his low back pain started in “July and August of 2006 after falling down stairs, landing on his buttocks and the rolling down the stairs striking his back.”  Physical examination showed ROM was limited by pain with flexion to 80 degrees, radicular symptoms starting at 50 degrees; extension to 30 degrees; lateral bending to 20 degrees; and bilateral rotation to 30 degrees.  All ROMs and repetitions were limited by pain.  

A physical medicine and rehabilitation evaluation on 20 September 2007, 2 months prior to separation, showed a “mildly antalgic gait favoring the left leg”, decreased left foot strength, absent left Achilles reflex, and decreased left lower extremity sensation.  A surgical consultation was initiated.  

A primary care evaluation on 09 October 2007, 1 month prior to separation, the CI reported back pain exacerbation.  The physical examination showed an abnormal gait, abnormal lumbosacral appearance, muscle spasm, and painful motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 10%, coded 5243 (Intervertebral disc syndrome), citing herniated nucleus pulposus.  The VA rated the degenerative joint disease with broad base bulge at L5-S1 and left sided radiculopathy condition 20% coded 5242 (Degenerative arthritis of the spine), based on the VA C&P examination 2 months after separation, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  

In considering other pathways to a higher rating, it was noted that muscle spasm associated with an abnormal gait and abnormal spinal contour was present on the late-August and October 2007 examinations.  Although this was an inconsistent finding, the panel concluded that there was sufficient reasonable doubt (§4.3) in favor of the CI to support a 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour).  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 low back pain condition, coded 5243.  

BOARD FINDINGS:  In the matter of the right patellofemoral syndrome condition, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the low back pain condition, the panel majority recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the contended right knee pain s/p ACL repair x 2 condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  The single voter for dissent submitted the appended minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Patellofemoral Syndrome	5299-5003	10%	
Lumbar Degenerative Disk Disease	5243	20%	
COMBINED	30%	

Voting Options:
1) No Rechat 
2) 5299-5003 @ 10% + 5243 @ 20% = Combined 30%
3) #### @ #0% + #### @ #0% = Combined #0%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
	 	- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USN
		-XXXXXXXXXXXXXXXXXX, former USMC