RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01439
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030910

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated  for “chronic back pain” and “bilateral patellofemoral pain syndrome,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:   “The pain has increased substantially over the years and is causing other issues which I have to manage.”  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 - 20030501	VARD - 20031204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5295	0%	Lumbar Strain	5292	0%	20031110	
Bilateral Patellofemoral Pain Syndrome	5099-5003	0%	Patellofemoral Syndrome, Right 	5257	10%		
			Patellofemoral Syndrome, Left 	5099-5003	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic back pain condition began in August 2002 after a fall from a military vehicle.  Radiologic imaging of the lower spine was normal.  Despite conservative treatment to include chiropractic manipulations, the CI could not be adequately rehabilitated to meet the physical requirements of his military specialty and was referred for an MEB.  The MEB forwarded “mechanical low back pain” for PEB adjudication.
At the 03 April 2003 MEB NARSUM examination, 5 months prior to separation, the CI endorsed a dull low back pain which radiated up to and between the shoulder blades and was aggravated by activities.  His functional limitations were described as walking a half of a mile and running a quarter of a mile before the onset of pain.  He reported the inability to kneel or squat due to pain.  His physical examination (PE) revealed local tenderness about the para-spinal muscle mass.  Thoracolumbar range of motion (ROM) was normal.  There was no comment regarding gait, painful motion, or abnormal spinal contour.  The provider noted, “The [CI’s] condition has remained stable over time and has not responded to rest, activity modification or time.”  At the 10 November 2003 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI endorsed a crushing sharp 10/10 low back pain that radiated up to his thoracic spine at least six times per day with a duration of up to two hours each episode.  His VA PE revealed a normal posture and gait.  A detailed spinal examination was completely normal with full ROM.  His diagnosis was listed as “lumbar strain.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 0%, analogously coded as 5299-5295 (lumbosacral strain), citing normal physical parameters; whereas the VA also rated the back condition at 0% under code 5292 (limitation of the lumbar spine) based upon the C&P examination 2 months after separation.  Pursuant to DoDI 6040.44, the panel is required to recommend a rating IAW the Veterans Administration Schedule for Rating Disabilities (VASRD) standards in effect at the time of separation.  The panel noted that the 2003 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The panel must correlate the above clinical data with the 2003 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome); and 5295 (lumbosacral strain).  Absent evidence of limiting spine motion or pathology of intervertebral disc syndrome, all panel members agreed that neither VASRD codes of 5292 or 5293 were applicable.  Members concluded that the absence of painful motion in the examinations near the time of separation did not support a minimum rating of 10%.  Based upon the above rationale, the panel members agreed that the PEB’s 0% rating was appropriate in this case.  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’s adjudication for the back pain condition.

The panel also considered if an additional disability rating was justified for peripheral nerve impairment due to radiculopathy/neuropathy.  Although the CI had subjective pain radiation up into his thoracic spine, its directional location was not anatomically consistent in reflecting a definite neuropathic etiology.   Panel members did not concede the presence of any adverse nerve pathology that adversely affected his ability to perform military duties; so, no additional impairment rating is recommended.    

Bilateral Patellofemoral Pain Syndrome (PFPS).  According to the STR and the MEB NARSUM, the CI’s bilateral knee/lower leg condition was first diagnosed as “mild shin splints” in 1999 after his first week of airborne school.  There was no history of direct trauma.  The next clinical encounter contained in the case file was dated 03 April 2003 whereby orthopedics listed the CI’s diagnosis as “bilateral PFPS”.  Bilateral knee x-rays were normal.  The MEB forwarded “bilateral PFPS” for PEB adjudication.

The MEB NARSUM PE revealed normal ROM of both knees excepting a bilateral deficit of 5 degrees of flexion (135 vs 140 degrees).  Tenderness was present upon the medial side of each kneecap.  Clinical maneuvers for testing instability were normal.  At the 2 month post separation VA C&P evaluation, the CI reported intermittent painful flare-ups of both knees twice a week with up to a 3-day duration each episode. His functional impairment was noted as “none”.  His VA PE of both knees revealed normal ROM.  All maneuvers of ligamentous instability tests were normal.  The provider noted “slight degree” of meniscal instability in the right knee. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions under a single disability rating, analogously coded 5003 (degenerative arthritis) and rated 0% citing normal examination findings.  The VA separately rated each knee at 10% (right knee) under code 5257 (knee; other impairment) and at 0% (left knee) under the analogous code 5099-5003 (degenerative arthritis) citing instability on the right and intermittent flare-up symptoms on the left.  

The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining the bilateral knee condition as a single rating was justified in lieu of separate ratings.  The panel must apply separate codes and ratings in its recommendations if compensable ratings for each extremity condition are achieved IAW VASRD §4.71a.  If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  Despite few historical clinical documents contained in the case file, all panel members agreed that the CI’s overall condition and isolated treatments did not significantly center about either knee independently, but rather a bilateral condition.  Members found it reasonable to surmise that it was the overall combination of pathology from both knees that rendered the CI unfit to perform his MOS duties.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the  panel  concluded that the physical evidence of near normal ROM as well as the slightest of meniscal instability on the right knee did not overcome any sufficient level of a disabling impairment as noted in the CI’s functional impairment documentation as being “none”.  Therefore, there was insufficient cause to recommend a change in the PEB’s adjudication for the bilateral knee condition.  

BOARD FINDINGS:  In the matter of the chronic back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral patellofemoral pain syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.   

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008499, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure