RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02212
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “bilateral lower leg and ankle pain” and “chronic low back pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The Board also reviewed the additional evidence received on 12 October 2016.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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.  Any conditions outside the Board’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 Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’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 Board 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 Board 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 - 20031202	VARD - 20040712	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Leg and Ankle Pain (includes the Knees)	5099-5003	10%	Residuals of Bilateral Avulsion Fractures of both Ankles and Stress Fractures of Both Shins	5299-5271	0%	20040325	
			Patellofemoral Syndrome Right Knee	5299-5260	10%	20040325	
			Patellofemoral Syndrome Left Knee	5299-5260	0%	20040325	
Chronic Low Back Pain	5237	0%	Degenerative Disc Disease, Lumbar Spine	5243	0%	20040325	
Mild Painful Pes Planus	Not Unfitting 	Bilateral Pes Planus	5299-5276	0%	20040325	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Lower Leg and Ankle Pain (Includes the Knees).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral lower leg and ankle pain (includes the knees) condition began in 1994 without a distinct traumatic event.  The MEB forwarded RPPS bilateral knees, chronic stress changes to bilateral tibias and bilateral ankle chronic sprains for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 3 September 2003, 5 months prior to separation, the CI reported bilateral knee pain when kneeling or squatting that locked up after a moderate amount of time.  The CI also reported bilateral lower leg pain with stress fractures and his feet hurt when participating in jumping or running type exercises.  Physical examination showed bilateral tenderness along the medial aspects of the tibia along the distal one-third to two-thirds, chronic knee pain and pes planus.  The MEB NARSUM examination on 31 October 2003, 3 months prior to separation, noted complaints of bilateral leg, knee and ankle pain.  Physical examination showed mild tenderness to palpation around the anterior aspect of the knees and pain with patellar grind.  Bilaterally, the legs were non-edematous, however there was tenderness to palpation along the anterior tibia with minimal pain.  The ankles demonstrated dorsiflexion to 20 degrees, plantar flexion to 35 degrees, stable to talar tilt and anterior drawer and did not have tenderness to palpation over the malleolar area.  The right and left knees demonstrated 155 degrees range of motion (ROM) in flexion (140 degrees normal) with associated tenderness to palpation.  

At the 25 March 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported pain in the shin area of the right lower leg with spasms to the ankles bilaterally.  Increased activity caused increase sensitivity to the shins.  The CI stated the pain was dull to sharp.  The CI reported that the ankle spasms caused a numbness resulting in lack of endurance and weakness, particularly if he sprained the area.  He reported a locking of the knees bilaterally when going up and down the stairs; the right greater than the left knee.  He reported weakness, lack of endurance and giving away of the knees bilaterally.  The CI stated that he did not use any assistance devices for ambulation.  Physical examination showed a non-antalgic gait.  The right knee exhibited tenderness to percussion without clicking or crepitance.  The left knee exhibited no tenderness to percussion.  The ROM was normal bilaterally, 0-140 degrees.  Right and left foot dorsiflexion and plantarflexion were 25 degrees and 40 degrees respectively, without evidence of swelling or edema.  The ankles demonstrated no restriction in ROM.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the bilateral knee, tibia, and ankle conditions under a single disability rating, coded analogously to 5003 and rated 10%, citing no loss of joint motion or evidence of joint instability.  The VA rated the bilateral lower leg and ankle pain conditions together and the bilateral lower knee conditions separately.  The bilateral lower leg and ankle pain conditions were rated as residuals of bilateral avulsion fractures of both ankles and stress fractures of both shins (also claimed as bilateral lower leg condition) coded 5299-5271 and rated as 0%.  The bilateral lower knee condition was rated as patellofemoral syndrome, right and left coded 5299-5260 rated 10% and 0% respectively.  The VA ratings were based on the VA C&P examination 5 months after separation, citing painful or limited motion of a major joint or group of minor joints, (the right knee in this case) and may also be applied once to multiple joints if there is no limited or painful motion.  An evaluation of 10 percent can also be granted for leg flexion which is limited to 45 degrees or extension limited to 10 degrees. A higher evaluation of 20% is not warranted unless evidence demonstrates leg flexion which is limited to 30 degrees or extension of the leg is limited to 15 degrees.  The bilateral lower leg and ankle pain condition did not meet criteria to warrant a compensable evaluation, therefore non-compensable.  

Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single Service disability rating must be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If Board members determine by performance based fitness criteria that the condition is reasonable justified as separately unfitting and is separately ratable separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single disability rating from the PEB.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The bilateral knee, tibia, and ankle conditions were profiled and referred by the MEB as failing retention standards.  Multiple treatment notes documented reports and treatment of bilateral knee, tibia, and ankle (Achilles) pain.  Radiographic and nuclear evaluation demonstrated knees, tibias, and ankles demonstrated stress reaction changes and small bilateral knee effusions.  Members agreed that the clinical and fitness performance evidence supports that each knee, tibia, and ankle could be reasonably justified as separately unfitting.  

The Board then considered its rating recommendations.  A 10% rating under the provisions of 5003 was considered for the bilateral knee and tibia.  The Board noted that the VA examination, 1 month after separation, was closer to the time of separation and therefore, placed higher probative value on that examination.  Board members agreed that there was radiographic evidence of knee and tibia pathology in conjunction with the absence of limitation of motion for a bilateral 10% rating.  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 bilateral knee, tibia, and ankle conditions.

The Board noted 5 degrees of limitation of motion in each ankle; however the limitation of motion did not rise to the level of moderate limitation of motion for the 10% rating under 5271 (ankle limitation of motion).  The Board also noted radiographic evidence of healed avulsion fractures and reports of pain with use; however, there was not any objective findings of ankle tenderness to palpation, edema, or swelling to support a 10% rating IAW §4.59 (painful motion) or §4.40 (functional loss).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for each ankle pain condition, coded 5271.  

Chronic Low Back Pain.  According to the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began in 1996 without incidence.  The MEB forwarded degenerative disk disease lumbosacral spine for PEB adjudication.  At a primary care clinic appointment on 2 August 2003, the CI presented with complaints of lower back pain for 2 days.  He said that he was lifting a heavy file cabinet when the pain occurred.  Physical examination showed decrease range of motion (ROM) of the lumbar spine with diffuse tenderness over the lumbar dorsal processes.  Radiographs of the lumbar spine were normal.  

The MEB NARSUM examination on 31 October 2003, 3 months prior to separation, noted complaints of non-radiating back pains mainly located in his lower back.  The CI stated that he had occasional flare-ups.  The CI reported no bowel or bladder changes.  Physical examination showed flexion at 90 degrees, extension at 20 degrees with pain mostly noted on extension, and right and left rotation were 30 degrees, thereby having a combined range of motion total of approximately 170 degrees to 230 degrees, assuming normal right and left lateral flexion (normal is 0 to 30 degrees each) motions.  Otherwise the CI’s back showed no scoliosis and full range of motion.  An Magnetic Resonance Imaging (MRI) study performed in October 2003, 4 months prior to separation, showed a bulging disk at L5/S1 area, no evidence of disk herniation, canal stenosis, lateral recess narrowing or foramen encroachment and a straightening of the lumbar lordosis related to muscle spasm.   

At the 25 March 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported lower back pain that felt like a “pulling of the muscle.”  He also stated that he was treated for the pain with muscle relaxants since approximately 2001 and that the pain had gotten much worse.  Physical examination showed the CI had difficulty lying down on the table, negative radicular testing, and a normal gait.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 0%, coded 5237 (lumbar spine strain), citing findings of degenerative disc disease, without radiculopathy, spasm, local muscle tenderness, or loss of motion.  The VA rated the back condition 0% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 2 months after separation, citing current condition is considered mild and warranted a non-compensable evaluation.  

The Board agreed that a 10% rating, but no higher, was justified for a combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM examination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic low back pain condition, coded 5237.  

Contended PEB Conditions:  Mild Painful Pes Planus.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended mild painful pes planus condition was not unfitting.  The VA examination noted intermittent foot pain.  X-rays revealed no abnormalities and ROM revealed no restriction to normal motion.  There was no tenderness, swelling or instability or other abnormality of either foot.  Posture and gait were normal.  There was no performance based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  The profile allowed for an alternate aerobic event.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS   In the matter of the bilateral knee and tibia pain conditions the Board determined that they were unfitting and recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the bilateral ankle conditions the Board determined that each ankle was unfitting and recommends a disability rating of 0% for each ankle , coded 5271 IAW VASRD §4.71a.  In the matter of the chronic lower back condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended mild painful pes planus condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Knee and Tibia Pain	5003	10%	
Lower Back Pain	5237	10%	
Right Ankle Pain	5271	0%	
Left Ankle Pain	5271	0%	
COMBINEDRATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150817, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
AR20170004249, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  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,