RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01842
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Light Wheel Vehicle Mechanic, medically separated for back pain without neurologic abnormalities and bilateral knee pain, rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 panel 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 determinations 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 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 - 20050304	VARD - 20050906	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Back Pain, w/o Neurologic Abnormality	5299-5237	10%	Mechanical Low Back Pain	5237	0%	2005011	
Chronic Bilateral Knee Pain	5099-5003	0%	Left PFS	5024	10%		
			Right PFS	5024	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first evaluated for low back pain (LBP) in June 2004 when she reported that she had strained her back the previous day at work.  One month later, she was seen by a chiropractor on 22 July 2004, 11 months prior to separation.  She was noted to have full range of motion (ROM) with a normal gait and motor examination.  She reported several episodes of LBP in the past which resolved within a few days.  She was seen several more times and noted to have tenderness, but to be free of spasm.  X-rays on 27 September 2004 were consistent with muscle spasm but otherwise without abnormality.  Two days later on 29 September 2004 in primary care she was noted to have normal sensation, strength, reflexes and full ROM.  She was again treated by a chiropractor on 6 October 2004 and noted to have tenderness but to be without spasm.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  

Formal ROM measurements were obtained in physical therapy on 25 October 2004, 8 months prior to separation and are recorded below.  The MEB examination 2 days later noted that provocative testing for nerve root irritation was negative and the neurological examination was normal.  

At the 11 January 2005 VA Compensation and Pension (C&P) evaluation, performed 5 months before separation, the CI reported pain which radiated to low back, left leg and left foot.  The CI noted no incapacitation and no lost time from work.  The CI’s pain was relieved with rest and medication.  The physical examination showed no radiating pain on movement; no muscle spasms; and no ankylosis of the spine.  Tenderness was present.  Her posture and gait were normal and signs of abnormal weight bearing were absent.  Pain was present with repetition, but there was no further decrease in the ROM.  The neurological examination was normal.  X-rays showed a congenital finding of no clinical significance, but other pathology was not recorded.

The MEB NARSUM examination on 26 January 2005, 5 months prior to separation, noted complaints of back pain which worsened with exertional activity, prolonged standing and prolonged sitting.  She reported 3 days of quarters in July 2003 (not in evidence).  The physical examination showed no significant tenderness and a normal gait.  Atrophy was absent and the muscle tone normal.  The ROM recorded was identical to the PT ROM measurements from October 2005, reducing the probative value of this examination.  The MEB forwarded “chronic low back pain” for PEB adjudication.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	MEB ~8 Mos. Pre-Sep	VA ~5 Mos. Post-Sep	
Flexion (90 Normal)	35	90	
Combined (240)	100	240	
Comments	Tenderness 	Painful motion.  No spasm.  Normal gait	
§4.71a Rating	20%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (lumbosacral strain).  The VA rated the back condition 0% coded 5237 (lumbosacral strain), based on the VA C&P examination 5 months before separation, citing full ROM with pain, no spasms and no TTP.  The limitation of flexion reported on the NARSUM examination supports a 20% rating, however this is identical to the measurements recorded on the physical examination several months earlier.  It is also an outlier from the VA examination and other clinical visits which recorded a normal ROM.  Finally, it is not consistent with the normal gait typically recorded or the absence of pathology present on X-rays.  The VA is therefore accorded a higher probative value for rating at separation.  Tenderness and painful motion both support a 10% rating at separation.  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 ratable peripheral nerve impairment which would provide for additional rating.  The neurological examination was normal on multiple examinations.  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 condition.  
Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single service disability rating coded analogously to 5003 and rated 0% with application of the USAPDA pain policy.  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 Board 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 Board’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 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 right and left knee conditions are presented together.  

According to STR and the MEB NARSUM, the CI’s bilateral knee condition began in May 2003 without specific trauma or injury.  X-rays on 10 March 2004 were normal.  A physical therapy examination on 24 August 2004, 10 months before separation, noted a negative McMurray test (test for knee cartilage damage) and moderate crepitus on the left and minimal crepitus on the right knee.  Despite treatment, the bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB NARSUM examination noted complaints of daily pain which worsened with bending, stooping and climbing.  The physical examination showed minimal tenderness; no joint effusion and no instability.  The gait was normal.  The ROM values are identical to the physical therapy values from October 2004.  

At the 11 January 2005 C&P evaluation, the CI reported crepitus, pain and swelling but no incapacitation.  The gait was normal.  The physical examination showed crepitus and joint line tenderness for both knees.  The examiner opined the ROM was limited by pain.  The ROM values are noted below.  X-rays were normal other than a possible loose body on the left.  The CI was diagnosed with bilateral patellofemoral syndrome (PFS).  The MEB forwarded “bilateral knee pain” for PEB adjudication.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Knee ROM
(Degrees)	PT ~8 Mo. Pre-Sep	VA C&P ~5 Mo. Pre-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	125	125	140	140	
Extension (0 Normal)	2	2	0	0	
Comment	TTP, No effusion, No instability, Nml gait	Painful motion, TTP, Crepitus, Nml gait	
§4.71a Rating	0%	0%	
§4.59 Rating	10% each knee	10% each knee	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5003 (arthritis, degenerative), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated the bilateral knee condition 10% for each knee coded 5024 (tenosynovitis), based on the VA C&P 5 months before separation, citing full range of motion with pain.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for both knees using the code 5003.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral knee condition, the Board unanimously recommends a disability rating of 10% for each knee coded 5024 IAW VASRD §4.71a.  There were 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; 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	
Chronic Back Pain	5299-5237	10%	
Chronic Left Knee Pain	5024	10%	
Chronic Right Knee Pain	5024	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170003952, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure