RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01614
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E7, Automated Logistics Specialist, medically separated for “chronic pain, right knee status post arthroscopy, and chronic neck pain, status post cervical fusion,” and “chronic low back pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the panel evaluate two not in scope conditions of “gastro esophageal reflux” and a “high hernia”.  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 - 20030725	VARD - 20020822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Knee… and Chronic Neck Pain	5293-5099-5003	10%	DDD claimed as Cervical Spine,
Injury	5293	NSC	20020709	
			No VA Placement for Right Knee	
Chronic Low Back Pain	5293- 5299-5295	10%	Degenerative Disc Disease claimed as Lumbar Spine Injury	5293	NSC	20020709	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Pain, Right Knee.  The PEB combined the right knee pain and chronic neck pain as a single unfitting condition coded 5293-5099-5003 (analogous to arthritis, degenerative (hypertrophic or osteoarthritis)) and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  The 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 panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore 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 each condition, the panel 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 panel 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 right knee pain and chronic neck pain are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain began in early 2000 with no apparent trauma.  She first was treated with oral anti-inflammatory medications and then a right knee injection with only minimal relief for a brief period of time.  She then underwent an arthroscopic lateral release in October 2000.  Despite the procedure, pain persisted and she was issued a permanent profile in May 2002.  She was treated with Physical Therapy (PT).  In February 2003 she was granted a US Army deployment exception to policy to deploy for operation Nobel Eagle (stateside activation).  When her deployment was changed to Kuwait a second exception to policy was requested primarily discussing the right knee pain which resulted in initiation of the MEB process.  Despite treatment, the right knee condition could not be adequately rehabilitated to allow her to deploy with her unit.  The MEB forwarded “degenerative joint disease, right knee (EPTS)” for PEB adjudication.  

At the May 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported persistent knee pain and occasional “giving out.”  The physical examination was only significant for tenderness over the right patella and was otherwise unremarkable.  The 21 May 2003 MEB NARSUM examination, 4 months prior to separation, noted complaints of persistent right knee pain.  Physical examination showed no motor or sensory deficit in the lower extremities and the CI could walk on her toes and heels without difficulty.  There was no muscle atrophy and deep tendon reflexes in the knees and ankles was 2+ (normal).  Range of motion (ROM) testing performed by physical therapy on 19 May 2003 recorded right knee flexion of 125 degrees (normal 140), and extension of 0 degrees (normal 0) which were both equal with the unaffected left knee.  The 9 July 2002 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, did not address the right knee pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the right knee pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel could not find evidence in the commander’s statement or elsewhere in the STR that indicated knee pain caused any significant interference with the performance of the CI’s duties.  The commander’s statement indicated none of the CI’s conditions or profile limitation significantly interfered with duty performance and recommended the CI be retained.  The permanent profile authorized the CI to perform the alternate 2.5 mile walk to satisfy the APFT 2-mile run requirement and march up to 4 miles.  However, evidence indicates the right knee pain was the sole condition that prevented the CI from deploying with her unit and the primary condition that initiated the MEB.  Panel members agreed that the evidence reasonably justified that the functional limitations associated with the right knee pain that rendered the CI non-deployable contributed to the CI’s inability to perform her military duties in a contingency area.  Accordingly, a separate disability rating is recommended.  The PEB combined the neck pain and right knee pain conditions and rated them 10%, coded 5299-5099-5003 (analogous to arthritis, degenerative (hypertrophic or osteoarthritis)), citing, the US Army Physical Disability Agency (USAPDA) pain policy.  

There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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 no evidence of painful motion with functional loss supporting a minimal rating (based on §4.59, §4.40 and §4.45).  No additional functional limitation was evidenced by the examinations.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right knee pain condition, analogously coded 5099-5003 (arthritis, degenerative).  

Chronic Neck Pain.  According to the STR and the MEB NARSUM, the CI’s chronic neck pain began in late 1999 with no apparent trauma.  The CI underwent surgery for cervical spinal fusion (C5/6) in July 2000.  Due to persistent neck pain radiating to both arms, she underwent a cervical myelogram which demonstrated bilateral foraminal stenosis at C3-4 which was above her prior fusion.  She required another surgery of the cervical spine with discectomy and C3-4 fusion in January 2002.  At MEB initiation due to the right knee pain discussed above, the MEB also forwarded “chronic neck pain, status post cervical spine fusion for disc disease (EPTS)” for PEB adjudication.  

At the May 2003 MEB examination the CI reported persistent neck pain that prevented her from wearing the army combat helmet (ACH).  Physical examination noted the scars from the spinal fusion surgeries but was otherwise unremarkable.  The 21 May 2003 MEB NARSUM examination, noted complaints of persistent neck pain.  Physical examination showed normal neurological functions.  ROM testing performed by physical therapy on 19 May 2003 recorded neck flexion of 40 degrees (normal 45), extension 20 degrees (normal 45), right lateral flexion 20 degrees (normal 45),  left lateral flexion 45 degrees (normal 45), right rotation 50 degrees (normal 45), left rotation 40 degrees (normal 45) with a combined ROM of 185 degrees.  Radiological studies were not available.  

At the C&P evaluation the CI reported recurrent soreness in the neck with pain, numbness and tingling in both arms down to the hands.  Physical examination showed two well healed surgical scars over the anterior neck with some tenderness to palpation on the lower left side of the neck.  ROM testing recorded neck flexion of 30 degrees, extension 25 degrees, right rotation 50 degrees, left rotation 45 degrees.  Right and left lateral flexion were not recorded.  No spasm or pain on motion was noted.  

At a 12 August 2003 Physical Medicine and Rehabilitation (PM&R) evaluation, 2 months prior to separation, the CI complained of continued neck pain with radiating into both shoulders and sometimes arms.  Physical examination noted “good” ROM and a negative Spurling’s test (test for radicular pain from the neck).  The PM&R physician opined that her pain and tightness of her neck seemed to be more myofascial in nature.  

The panel directed attention to its rating recommendation based on the above evidence.   The PEB combined the right knee pain and chronic neck pain as a single unfitting condition coded 5293-5099-5003 (analogous to arthritis, degenerative (hypertrophic or osteoarthritis)) and rated 10% with application of the USAPDA pain policy and AR 635-40 B24.f.  The 9 July 2002 VA rating decision did not service-connect the cervical spine condition based on the STR and the C&P evaluation, citing it was “neither occurred in, nor was caused by, service.”  The panel first considered if the chronic neck pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel could not find evidence in the commander’s statement or elsewhere in the STR that indicated any significant interference of with the performance of duties.  The commander’s statement indicated that none of the CI’s conditions or profile limitation significantly interfered with duty performance and recommended the CI be retained and deployed.  The panel noted that the permanent profile does not allow for the wear of any protective gear including not to wear the ACH or other body armor.  Therefore, the panel concluded that the preponderance of evidence showed the chronic neck pain would have reasonably have caused the CI to be referred into the DES or be found unfit due to the neck pain condition.  

There was evidence from both the PT examination for the MEB NARSUM as well as from the C&P evaluation of limitation of forward flexion of 30 degrees but not more than 40 degrees to substantiate a 10 % rating using code 5241 (spinal fusion).  There was no evidence of forward flexion of less than 30 degrees to validate the next higher rating.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of unfitting peripheral nerve impairment which could provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic neck pain condition, coded 5241.  

Chronic Low Back Pain.  According to STR and the MEB NARSUM, the CI’s chronic low back pain (LBP) condition began in June 2001 with no apparent trauma.  An MRI in October 2001 showed disc bulges with moderate spinal stenosis at L3-4 and L4-5.  The CI underwent disc surgery of the lumbar spine in November 2001.  Despite surgery, the lumbar spine 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 “chronic low back pain, status post lumbar disc surgery (EPTS)” for PEB adjudication.  

At the May 2003 MEB examination the CI reported persistent low back pain that prevented her from standing long periods of time.  Physical examination noted the scars from the lumbar disk surgery, but was otherwise unremarkable.  The 21 May 2003 MEB NARSUM examination noted complaints of persistent low back pain.  Physical examination showed normal neurological functions and negative straight leg raise test (test for lumbar radiculopathy).  ROM testing performed by physical therapy on 19 May 2003 recorded low back flexion of 80 degrees (normal 90), extension 30 degrees (normal), right flexion 20 degrees (normal 30), left flexion 15 degrees (normal 30), right rotation 45 degrees (normal 30), and  left rotation 40 degrees (normal 30) with a combined ROM of 205 degrees (normal 240).  The 9 July 2002 C&P evaluation did not address the low back pain condition.  At a 12 August 2003 PM&R evaluation the CI presented for a pain evaluation.  She reported other various pains but there was no discussion of low back pain.  Physical examination revealed normal gait, “good ROM” and negative straight leg raising.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain 10%, coded 5293-5099-5003 (analogous to arthritis, degenerative (hypertrophic or osteoarthritis)), citing the USAPDA pain policy.  The VA did not service-connect the low back condition, based on the STR and the C&P examination citing “no evidence of injury to the lumbar spine while on active duty.”  

There was limitation of motion greater than 60 degrees but not greater than 85 degrees to support a 10% rating coded 5242 (degenerative arthritis of the spine).  There was no limitation of forward flexion less than 60 degrees, muscle spasm or guarding, thus the next higher 20% rating was not justified.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of unfitting peripheral nerve impairment which could provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic low back pain condition, coded 5242.  

BOARD FINDINGS:  In the matter of the right knee pain condition, the panel unanimously recommends a disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the chronic neck pain condition, the panel unanimously recommends a disability rating of 10%, coded 5241 IAW VASRD §4.71a.  In the matter of the low back pain condition, the panel unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  There are no other conditions within the Board’s scope of review for consideration.  

The panel 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	
Right Knee Pain	5099-5003	0%	
Chronic Neck Pain	5241	10%	
Chronic Low back Pain	5242	10%	
COMBINED	20%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20150623, with attachments  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20170008706, XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability description should be modified.  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