RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01721
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Construction Equipment Repairer, medically separated for “low back pain” and “right knee pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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  - 20090218	VARD - 20080623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Low Back Condition	5237	NSC	STR	
Right Knee Pain 	5299-5257	10%	Right Knee Condition	5299-5261	NSC	STR	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in 2003 after falling from a five-ton truck which resulted in an injury to the CI’s back and right knee.  Comprehensive physical therapy rehabilitation followed without significant relief of symptoms.  The CI left the service for other than medical reasons but, returned to active duty on 12 October 2006.  Since that time, the CI underwent an orthopedic evaluation for his back and right knee.  There was no surgical indication and conservative treatment was recommend.  Spine radiographic studies in August 2007 were normal.  After extensive therapy and medications the low back condition could not be adequately rehabilitated and the MEB forwarded “Nonradicular lower back pain.  Clinical findings do not support patient’s chief complaint” for PEB adjudication.  

During the August 2007 MEB examination (recorded on DD Forms 2807 and 2808) 6 months prior to separation, the CI reported lower back pain.  Physical examination showed pain to the lumbosacral spine with bending and squatting.  Straight leg raise (herniated disk test) was negative and toe walk was decreased on the left side.  An MRI dated 6 September 2007 showed multilevel mild degenerative disc disease with no evidence of disc herniation or central or lateral stenosis.  The 19 October 2007 MEB NARSUM examination, 4 months prior to separation, noted no neurologic complaints to include numbness or tingling in lower extremities.  No pain was reported with coughing, sneezing, or bearing down with bowel movements.  No bowel or bladder dysfunction was reported.  Physical examination showed full range of motion (ROM) and tenderness to palpation along the lumbosacral paraspinous region with no spasm noted.  

At the Physical Therapy evaluation in conjunction with the MEB NARSUM on 31 October 2007 the CI rated pain as 5-7/10.  Physical examination showed ROM measurements of forward flexion of 70 degrees (normal 90), extension 15 degrees (normal 30), left lateral flexion 25 degrees (normal 30), right lateral flexion 20 degrees (normal 30), left lateral rotation 15 degrees (normal 30) and right lateral rotation 10 degrees (normal 30) for a combined ROM of 155 degrees (normal 240).  In each case motion was recorded as being limited by pain.  Tenderness with palpation over the paraspinous muscles from T12 to S1 was noted.  Gait was unremarkable and no alteration of spinal contours were noted.
  
At the 15 January 2009 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported worsening constant back pain.  The CI denied bowel or bladder incontinence and no numbness or tingling in the legs reported.  Physical examination showed normal gait, muscle tone and strength in upper and lower extremities.  The lumbar ROM was recorded as forward flexion of 90 degrees (normal 90) with pain at 50, and a combined ROM of 240 degrees.  There was no additional limitation of ROM on repetitive use of joints due to pain, fatigue, weakness or lack of endurance.  X-rays and MRI were normal.  Mild tenderness on palpation was noted by the examiner. 

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5299-5237 (lumbosacral strain), citing full ROM with tenderness to palpation to the lumbosacral paraspinous region.  The VA did not service connect the back condition.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and a combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT examination.  The PT and NARSUM examinations noted the presence of painful motion and localized tenderness which also supports a 10% rating.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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). There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  
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 low back condition.  

Right Knee Pain.  According to the STR and the MEB NARSUM, the CI’s right knee condition began in 2003 after falling from a five-ton truck.  Extensive physical therapy rehabilitation followed without significant relief of symptoms.  The CI left the service for other than medical reasons but, returned to active duty on 12 October 2006.  Since that time, the CI underwent an orthopedic evaluation for his right knee.  There was no surgical indication and conservative treatment was recommended.  An MRI of the right knee on 12 February 2007 was normal.  After extensive therapy and medications the right knee condition could not be adequately rehabilitated and the MEB forwarded “mild Osgood-Schlatter disease of the right knee (This is non-service related but aggravated by related physical activities)” for PEB adjudication.  The MEB NARSUM examination on 19 October 2007, 4 months prior to separation, noted no complaints of popping, locking, or giving way.  Pain was primarily in the front of the knee.  Pain was described as constant, rated 5/10 not relieved with pain medication or activity modifications.  The CI was not able to wear military equipment, run, jump, squat, lift or climb.  Physical examination showed full ROM with tenderness to palpation along the anterior aspect of the right knee.  Knee radiographic studies done on 17 December 2007 suggested Osgood-Schlatter apophysitis and no other pathology.  At the MEB PT ROM evaluation on 31 October 2007, 4 months prior to separation, the right knee ROM was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal 0).  Limitation of motion was due to pain.  Lachman’s testing was negative.  At the 15 January 2009 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported achy pain made worse with walking and climbing stairs.  The CI denied any recent swelling, redness, or effusion of the right knee.  Physical examination showed flexion to 140 degrees (normal 140) and extension to 0 degrees (normal 0).  ROM was not painful.  There was not any additional loss in ROM on repetitive use due to pain, fatigue weakness or lack of endurance.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee 0%, coded 5099-5003 (analogous arthritis, degenerative), citing the US Army Physical Disability Agency (USAPDA) Pain Policy.  A year after the CI was separated, the USAPDA completed an Administrative Correction based on disability rating guidance required by NDAA 2008.  The right knee rating was increased to 10%, citing minor functional loss caused by pain from repeated use.  The VA did not service connect the right knee condition.  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 supporting a minimum compensable rating of 10% IAW §4.59.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under the respective codes.  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the Service 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 adjudication for the right knee condition.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the right knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the adjudication.  There were 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 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170005120, XXXXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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