RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02005
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Naval Reserve E2, non-rated, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board consider 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 - 20050513	VARD - 20060530	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Low Back Strain	5237	10%	20060322	
Chronic Right Knee Pain	Category III	Patellofemoral Pain Syndrome, Right Knee	5261	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in 2002 after doing sit up exercises during initial entry training.  The back pain persisted, but was not debilitating until 2004, when it became chronic and severe during a period of active duty for training.  There was no surgical indication.

At the 8 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported chronic back pain with a “herniated disk.”  Physical examination showed pain over the S1 joint.  The MEB NARSUM examination on 25 March 2005, 4 months prior to separation, noted complaints of severe and unremitting back pain.  She was unable to walk long distances, sit for long periods of time, could not ascend or descend stairs, run and stoop to pick things up.  Physical examination showed a “slow and antalgic gait.”  Bilateral straight leg raises caused pain in the right para spinal and sacroiliac joint areas.  Tenderness to the right sacroiliac joint region and right para spinal facet region of the lower back was noted.  Range of motion (ROM) was noted as “limited” in forward flexion with right-sided sacroiliac joint and there was low back pain upon rotation and abduction motion.  Strength was normal but limited by pain.

At the 22 March 2006 VA Compensation and Pension (C&P) spine evaluation, 9 months after separation, the CI reported severe, daily, throbbing low back pain with radiation into the right leg, but denied any incapacitating episodes.  Physical examination showed normal spine curvature and symmetry with tenderness at L5-S1 region of the lumbar spine.  Antalgic gait to the right “secondary to knee pain” and the use of a crutch to ambulate was noted.  ROM testing recorded 90 degrees forward flexion (normal), 30 degrees extension (normal), 30 degrees right and left lateral bend (normal) and 30 degrees right and left rotation (normal).  Pain was noted on flexion and extension and noted as absent on lateral bending and rotation motions.  No muscle spasm or weakness was noted and sensory examinations throughout all segments/dermatomes were normal.  Straight leg test was positive to the right.  Repetitive motion resulted in no change in baseline testing with no increased pain, weakness, fatigue, lack of coordination.  The examiner referenced magnetic resonance imaging (MRI) studies of the lumbar spine in April 2004 that revealed posterior disk bulging with mild impression at L3, with lesser extent at L2 and L5, with facet hypertrophy at L3.  There was no evidence of central spinal stenosis or overt disk protrusion or extrusion.  X-rays taken at the same time as the 2004 MRI were normal.  The examiner noted no new radiographic studies were needed.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain 10%, coded 5237 (lumbosacral or cervical strain).  The VA also rated the back pain 10% coded 5237 (lumbosacral or cervical strain), based on the C&P Spine examination 8 months after separation, citing “painful or limited motion of a major joint or group of minor joints.” 

Although there was insufficient limitation of motion to support a minimum rating, the panel agreed a 10% rating was justified for the presence of painful motion.  There was no spinal contour or muscle spasm or guarding severe enough to result in an abnormal gait (antalgic gait was noted but was secondary to right knee pain per the above referenced C&P spine evaluation), thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula, or evidence of ratable peripheral nerve impairment which would provide for additional 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 pain.

Chronic Right Knee Pain.  According to the STR and NARSUM the CI’s right knee pain began during the same time her back.  

At the 8 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported pain in the right and left knees.  Physical examination showed right greater than left knee pain with “full ROM” and a positive subluxation test.  

The 25 March 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of moderate to severe right knee pain and stiffness resulting in the inability to ascend or descend stairs or run.  Physical examination showed no joint line tenderness with negative Lachman’s test.  ROM examination noted “approximately 20 to 100 degrees” with pain at both extremes of motion.  Right knee strength was normal but limited by pain.  An MRI of the right knee in June 2004 was normal and the examiner noted no new radiographic studies were needed.

At the 22 March 2006 VA Compensation and Pension (C&P) joints evaluation, 9 months after separation, the CI reported bilateral knee weakness, stiffness, and swelling with severe pain and instability in the right knee.  The CI additionally reported using a crutch and occasionally used a right knee brace for ambulation.  She worked part-time as a court reporter in August 2005 for less than one month due to bilateral knee pain.  She was able to perform laundry and dishes but had difficulty with stopping, climbing stairs and vacuuming due to knee pain.  Physical examination showed the right knee tender along the medial and lateral retinaculum as well as at the patellar tendon.  The right knee was stable to varus and valgus stress, and was negative for anterior and posterior drawer tests.  McMurray's and Lachman's tests were also negative.  ROM testing recorded 120 degrees flexion (140 normal) and 0 degrees extension (normal) with pain.  Repetitive motion testing resulted in no change in baseline testing with no increased pain, weakness, fatigue, lack of coordination, or ROM.  Contrary to the C&P spine examination on the same day, the CI demonstrated a “normal gait without functional limitations.”  The examiner specifically noted “no unusual shoe-wear pattern that would indicate abnormal weight bearing.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the right knee pain was not unfitting and therefore assigned no rating, designating it as Category III.  The VA rated the right knee pain 10% coded 5261 (leg, limitation of extension of), based on the C&P joints examination 9 months after separation, citing “limitation of motion based on pain.”  As a Navy category III condition (conditions that are not separately unfitting and do not contribute to the unfitting condition) and because the CI specifically requested consideration, the panel considered the PEB’s fitness determination of the right knee.  The panel found the preponderance of evidence justified the right knee pain as an additional unfitting condition.  The panel next deliberated the appropriate rating for the right knee.  The panel considered the probative value of the MEB NARSUM examination on 25 March 2005, 3 months prior to separation, and the 6 March 2006 C&P joints evaluation, and performed 6 months after separation.  The VA C&P Joints examination was much more detailed and recorded precise ROM measurements and therefore was adjudged to be of greater probative value.

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 with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  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 mal union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 right knee pain, coded 5003.  

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, the panel recommends it as an additionally unfitting condition with a disability rating of 10%, coded 5261 IAW VASRD §4.71a.  There are no other conditions within the panel’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	
Chronic Low Back Pain	5237	10%	
Chronic Right Knee Pain	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150722, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 07 Jul 17 XXXXXXXXXXXXXXXXXX
 
	(c) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(d) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(e) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX

	(f) PDBR ltr dtd 03 Aug 17 XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.       

     e. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.      
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXX

	Acting