RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01857
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051019

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cable System Instillation/Maintenance, medically separated for “chronic low back pain [LBP]” and “[bilateral] retro-patellar knee pain,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

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 PEB - 20050914	VARD – 20051122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	0%	Residuals Lower Back Injury	5237	0%	20050926	
[Bilateral] Retro-patellar Knee Pains 	5099-5003	0%	Chondromalacia Left Knee	5299-5020	0%		
			Chondromalacia Right Knee	5299-5020	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Chronic LBP.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in December 2001 after he fell on his back with a radio on his back and slid down the slope of a hill.  He was treated with medications and duty restrictions over the next few years, but his pain persisted.  A primary care examination on 10 March 2005, 7 months before separation, noted complaints of back pain.  The physical examination revealed a normal spine curvature and full range of motion (ROM) in all planes without pain.  The gait was normal.  
At the 13 June 2005 MEB NARSUM examination, 4 months prior to separation, the CI reported constant back pain aggravated with running, walking, prolonged standing, and climbing up and down stairs.  The physical examination revealed tenderness of the lower thoracic area.  Strength and sensation were intact.  One sign of non-organic pain was positive.  The ROM was full.  No comment was made on painful motion.  Provocative testing for nerve root irritation was negative when seated, but positive on the right when lying supine.  X-rays of the thoracic and lumbar spine were normal in March 2005.  The ROM measurements for the MEB were accomplished in physical therapy on 28 June 2005.  These were for the lumbar spine apparently rather than the VASRD compliant thoraco-lumbar ROM.  The probative value of this examination is accordingly reduced.  Flexion was to 40 degrees (normal ~60) without painful motion.  

At the 26 September 2005 VA Compensation and Pension (C&P) evaluation, 3 weeks prior to separation, the CI reported ongoing LBP since 2001.  Incapacitation was not recorded.  The physical examination showed a normal gait and posture without para-spinal spasm.  Repetitive ROM was normal with flexion of 90 degrees (normal 90) and a combined ROM of 240 (normal 240) without painful motion.  The neurological examination was normal.  X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition 0%, coded 5237 (lumbosacral strain), citing that the ROM was reduced due to pain.  It also noted that 1 of 5 signs of non-organic pain was positive.  The VA also rated the back condition 0%, coded 5237 (lumbosacral strain), based on the C&P examination less than 1 month before separation noting no spine pathology on the examination, but that the CI was diagnosed with mechanical back pain while in service.

While tenderness of the thoracic paraspinal area was noted on the NARSUM examination, it had not been documented on the previous primary care evaluation and was not present on the VA C&P which was accomplished a few weeks before separation.  The latter was the most proximate evaluation to separation and was consistent with the totality of evidence and the objective findings.  It is therefore assigned a higher probative value for rating at separation.  A 0% rating is supported by this examination.  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 chronic low back pain condition.  

Retropatellar Knee Pain (Left and Right).  According to the STR and the MEB NARSUM, the CI’s first began in September 2000 during basic training associated with increased activity.  He was treated with medications, duty limitations, physical therapy, and partial weight bearing.  He was ultimately able to complete training, but the records fall silent from the end of September 2000 until April 2003 when he reported left knee pain associated with running for the past 1 ½ years.  The right knee was no longer as problematic.  X-rays of the left knee were negative.  He was treated again with duty limitations and physical therapy, but his pain persisted.  An MRI on 21 June 2004 showed bilateral patellar chondromalacia (degeneration of the cartilage lining of the kneecaps: chondromalacia patella [CMP]).  In primary care on 15 March 2005, the knees were stable and had full range of motion (ROM).  X-rays of both knees were normal.  Three weeks later in a follow up appointment, the CI reported chronic bilateral knee pain which had not improved with a profile and physical therapy.  A patella-femoral grind was positive, consistent with CMP.  The knees were stable and ROM showed normal extension with flexion reduced 5 degrees from normal to 135 degrees.  The commander’s performance statement, on 31 May 2005, 5 months before separation, implicated both knees which rendered the CI unable to perform his military specialty.  

The MEB NARSUM examination noted complaints of constant back pain aggravated with running, walking, prolonged standing, and climbing up and down stairs.  Physical examination recorded on the DD Forms 2807 and 2808 dated 10 June 2005, instability or meniscal impairment, and ROM was full; painful motion was not addressed.  An orthopedic examination on 23 June 2005, 4 months before separation, noted complaints of chronic bilateral knee pain since 2000.  The physical examination revealed a normal gait and full, pain free ROM bilaterally.  The knees were stable and without signs of meniscal disease.  A physical therapy examination for the MEB dated 28 June 2005, revealed bilateral ROM from 0-135 degrees; there was no change with repetition.  Painful motion was not addressed.  

At the C&P evaluation the CI reported bilateral knee pain.  He denied any specific trauma.  The physical examination showed a normal gait and posture.  There was not instability or meniscal impairment.  The ROM was full and pain free.  The X-ray studies were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5299-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated each knee condition 0% each, analogously coded 5299-5020 (synovitis) based on the C&P examination less than 1 month before separation, citing no knee pathology but diagnosed with chondromalacia while in service.

The PEB combined the left and right knees as a single unfitting condition analogously coded 5099-5003 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 panel also noted that “bundling,” the combining of 2 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 2 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 panel members noted that both knees were profiled, cited by the commander as impairing duty, and found to fail retention standards by the MEB.  The panel members agreed that each knee was reasonably conceded as separately unfitting.  

The panel then considered the evidence.  An MRI 16 months prior to separation noted bilateral chondromalacia of the patellae.  Multiple X-rays subsequent to it were normal though including X-rays obtained a few weeks prior to separation.  Painful motion was not present in the examinations proximate to separation.  The gait was recorded as normal.  The ROM was recorded as normal on multiple examinations, but limited to 135 on several as well.  The medical officer observed that 135 degrees flexion is not the VA normal (which is 140), but is considered normal by other medical entities.  Signs of meniscal impairment were absent as was instability.  Neither swelling nor muscle spasm were documented.  A bilateral 10% rating under the provisions of 5003 was considered, but there was no evidence of swelling, painful motion, or muscle spasm in the examinations proximate to separation.  There was no limitation of motion on most examinations and the 135 degrees of flexion noted on some examinations was not compensable.  The panel found no route to a compensable rating for the knees when rated either together or separately.  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 bilateral knee condition.

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the (bilateral) retropatellar knee pains condition, the panel 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150707, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009221, 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