RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02403
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Food Service Specialist, medically separated for “chronic subjective back pain” and “chronic pain right knee,” rated 10% each, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI’s main contention is with Veterans Affairs for denying her claim for disability benefits, but she does list her back and right knee conditions in her application.  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 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 – 20050518	VARD - 20050808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Back Pain	5299-5237	10%	Low Back Pain	5237	NSC	20050708	
Chronic Pain Right Knee	5099-5003	10%	Right Knee Pain	5299-5257	NSC	20050708	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2003 while performing sit-ups at basic training.  The CI graduated from basic training and was released from active duty on 23 October 2003.  On 24 December 2003, her commander completed a “Statement of Medical Examination and Duty Status,” but this document was never approved by the CI’s chain of command.  On 30 December 2003 the CI sought non-military medical care at the local VA medical center in Jackson, MS.  Radiographic studies from the clinic visit were normal.  On 8 December 2004, the CI was sent to a fit for duty evaluation and was found not able to perform her military duties.  

During the 3 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported an inability to lift heavy items, carry things, stand for long periods of time, or bend.  The documentation under CLINICAL EVALUATION showed that item 36.  Spine, other musculoskeletal was checked “Normal.”  The 7 March 2005 MEB NARSUM examination, 4 months prior to separation, showed that the CI’s back pain was made worse with standing, bending, and walking.  The NARSUM author referenced the DD Form 2808.  At the 22 March 2005 physical therapy (PT) evaluation, goniometer measured lumbar spine range of motion (ROM) showed flexion 60 degrees (normal 90) and combined 125 degrees (normal 240).  The examiner noted “slight/moderate discomfort during Lumbar extension.”  At the 31 March 2005 PT evaluation, lumbar spine ROM showed flexion of 60 degrees and combined of 120 degrees.  At the 12 May 2005 PT evaluation, goniometer measured lumbar spine ROM was flexion of 50 degrees and combined of 140 degrees.  The examiner noted “with pain limitations.”  At the 8 July 2005 VA compensation and pension (C&P) evaluation, 6 days before separation, the CI stated “she was doing exercise as a group when she experienced a pop in her low back associated with the pain.”  She denied radiation of pain, flare-up episodes, unsteadiness, falls, or use of a cane, crutches, or any assistive device.  The CI could walk ½ mile without difficulty, but symptoms were exacerbated by prolonged standing (> 45 min.) and running.  “In the past 12 months, there has been no episodes during which bedrest was prescribed.”  There was no history of surgery on the back or any recommended surgery.  The physical examination documented a normal gait.  “The veteran got on and off the table without difficulty.”  The spine examination revealed “near normal curvature with very slight increased lumbar lordosis [anterior spine curvature].  There is some very mild muscle spasm in the right lumbar musculature parallel to the spine.”  There was no evidence of scoliosis (abnormal lateral spine curvature) or spinal muscles tenderness.  The thoracolumbar spine ROM values were flexion of 70 (90 normal), extension of 20 (30), right lateral flexion of 30 (30), left lateral flexion of 30 (30), right rotation of 24 (30), left rotation of 24 (30), and combined of 200 (240) degrees.  “After repetitive motion forward flexion is 0-60 degrees … after repetitive motion left lateral flexion 0-20 degrees … after repetitive motion right lateral flexion is 0-20 degrees.”  There was no evidence of painful motion or other evidence of weakness.  The straight leg raise ([SLR] assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) tests were negative.  Waddell’s signs (psychogenic, or nonorganic, manifestations of pain) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of a normal lumbar spine X-ray.  The diagnosis listed mild muscle spasm, right lumbar muscles.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing “ROM limited by pain.”  The VA found the back condition to be not service connected and did not rate it.  The panel noted the LOD investigation for the CI’s back condition was never properly completed or approved.  The VA C&P examination ROM values were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The three PT examinations ROM values were consistent with the 20% rating.  The panel assigned more probative value to the VA C&P examination because it measured repetitive thoracolumbar spine ROM.  The panel assigned less probative value to the 3 PT examinations because they measured lumbar spine ROM.  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 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.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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.  

Chronic Pain Right Knee.  According to the STR and the MEB NARSUM, the CI’s right knee condition began after the CI returned home from her initial entry training and was first mentioned in the incomplete informal LOD investigation paperwork for the back on 24 December 2003.  However, other than the MEB indicating that the right knee condition was incurred while entitled to base pay, there was no evidence in the case file showing that the right knee was injured while entitled to base pay.  Radiographic studies were normal.  The CI was referred to PT, however the CI could not tolerate the PT and reported “that the crepitus in her knee increased with PT”.  She was referred to orthopedics, but that consultation was never accomplished.  On 8 December 2004, she was sent to a fit for duty evaluation and was found to not be able to perform her military duties.  During the 3 January 2005 MEB examination (DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported that her “knee pain comes from back problems.”  On examination, the examiner noted full knee flexion “with discomfort,” but did not indicate definitively which knee was affected.  There were no other pertinent findings from this examination.  

The 7 March 2005 MEB NARSUM, 4 months prior to separation, indicated that the right knee pain was made worse with standing, bending, and walking.  The 22 and 31 March 2005 PT right knee ROM values were flexion of 80 (140) and extension of 0 (0) degrees.  The 12 May 2005 PT right knee ROM was flexion of 90 (140) and extension of -5 (0) degrees.  At the 8 July 2005 VA C&P evaluation, 6 days before separation, the CI denied any specific accident involving the right knee.  The CI reported that her right knee pain radiated from her back pain, but was present at times without back pain.  She also reported her right knee pain was aggravated by prolonged standing.  On examination her gait was normal.  She had some crepitus with passive motion especially at full extension, but there was no pain at this extreme.  Pain-limited right knee ROM was flexion of 60 degrees (normal 140) and extension of 0 degrees (normal 0) degrees.  Repetitive pain-limited right knee ROM was flexion of 42 degrees and extension of 0 degrees.  The CI stated that she had pain with flexion testing.  Her right calf muscle was 4 mm smaller than the left.  Tests for ligamentous instability were negative, but tests for meniscal pathology were positive.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA found the right knee condition to be not service connected and did not rate it.  The VA examination recorded right knee flexion limited to 42 degrees following repetitive motion supporting a 10 % rating (code 5260).  There was no limitation of extension that supported a rating higher than 0% under the VASRD diagnostic code for limitation of extension (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), 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).  No additional functional limitation was evidenced by the examinations.  There is 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.  

BOARD FINDINGS:  In the matter of the 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 PEB adjudication.  There are 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 20150706, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012633, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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