RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00001
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Special Electrical Device Repairer, medically separated for “chronic low back pain…,” “chronic bilateral knee pain,” and “major depressive disorder,” rated 10%, 10%, and ---% (existed prior to service [EPTS]), respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contended a higher rating for her 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 - 20070710	VARD - 20080730	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	10%	Herniated Nucleus Pulposus…	5243	NSC	STR	
Chronic Bilateral Knee Pain	5099-5003	10%	Left Knee Condition	5299-5260			
			Right Knee Condition				
MDD	9434	---%	Major Depressive Disorder	9434	30%	20080621	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first treated for low back pain (LBP) in September 2005 when she complained of a 10 day history of LBP aggravated by lifting weights.  She was treated with medications and duty limitations, but her pain persisted and she was referred to physical therapy.  On 20 September 2005, she was noted to have full range of motion (ROM) with minimal pain.  The neurological examination was normal.  She also reported numbness and pain in the lower extremities.  On 23 November 2005 computed tomography (CT) scan was remarkable for a herniation at L5-S1 with displacement of the right S1 nerve root.  On 27 February 2006 x-rays were normal.  The CI reported ongoing LBP and remained on duty limitations.  On 7 July 2006, she was noted to have a normal motor examination and gait was well as normal movement of all extremities.  A steroid injection provided relief for a few days, but then her pain recurred and was worse than before the injection.  The panel observed that the PEB combined (LBP), herniated intervertebral disc, and sciatica into a single condition for rating.  As discussed below, the panel determined that this was appropriate.  

During the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 7 September 2006, 15 months prior to separation, the CI reported sciatica and that she walked with a cane.  On examination, she was noted to have limited ROM in all planes and that her pain radiated to her right foot.  The neurological examination was normal.  

The MEB NARSUM examination was performed on 22 November 2006, 11 months prior to separation.  The CI reported that her LBP began in basic training.  She denied any specific injury.  She endorsed some improvement in her symptoms, but was not able to return to full duty.  On examination, tenderness, spasm, and an antalgic gait (abnormal due to pain) were present.  Four of five maneuvers which were not expected to be painful with this condition were, reducing the probative value of the examination.  Atrophy was absent and the neurological examination was normal.  The ROM was reduced with a rounded flexion of 55 degrees (90 is normal) and a rounded combined ROM of 95 (240 is normal).  

At the 23 March 2007 physical medicine evaluation, 7 months prior to separation, the CI reported bilateral leg weakness and LBP.  On examination, she was noted to have full, but painful lumbosacral ROM.  The neurological examination and gait were normal.  Electrodiagnostic studies done that day were significant for a right sural (lower leg peripheral nerve) neuropathy, but there was no evidence for a radiculopathy.  On 11 July 2007 magnetic resonance imaging (MRI) showed degeneration of the disc without herniation or nerve root impingement.  

An ambulatory care nursing note (a screening note for the VA Compensation and Pension [C&P] gynecology evaluation) recorded a normal gait on 15 January 2008, 3 months after separation.  

At the 10 October 2008 VA Compensation and Pension (C&P) evaluation, 12 months after separation, the CI reported ongoing LBP and 10 days of incapacitation (this was not documented in the service treatment records).  On examination, the gait and neurological examination were normal.  The ROM testing showed flexion of 70 degrees and a combined ROM of 190 degrees.  
The panel directed attention to its rating recommendation based on the above evidence. 

The PEB rated the LBP condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing palpable spasm and protruding disc.  As noted the PEB combined multiple conditions.  The panel observed that separate ratings for the LBP and herniated disc conditions would violate VASRD §4.14 (avoidance of pyramiding).  A combined rating was therefore appropriate.  A separate rating for a radiculopathy would not violate VASRD §4.14, but was not warranted as discussed below.  The VA initially did not service connect the LBP condition, coded 5243 (intervertebral disc syndrome), based on the service treatment record, citing no medical evidence of permanent residual disability and failure to keep the initial C&P appointment.  Subsequently, the VA rated the back at 10% retroactive to separation.  The panel considered the evidence.  The ROM measured at the MEB examination supported a 20% rating as did the abnormal gait and spasm.  However, multiple subsequent examinations showed improved ROM and a normal gait without spasm.  These were also more consistent with the demonstrated pathology and with each other.  The MEB examination was compromised by the presence of multiple signs of non-organic pain.  Accordingly, the VA examination was used for rating purposes and supported a 10% rating.  Multiple examinations demonstrated a normal neurological examination and the electrodiagnostic studies did not support the presence of a radiculopathy.  Accordingly, an unfitting radiculopathy was not shown to be present at separation and a separate rating is not supported.  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 condition.  

Bilateral Knee Pain.  After review of the records in evidence, it is unclear when the CI’s knee condition began.  The CI was entered into the MEB process for her LBP and initially no mention is made of the knees in the NARSUM, on the DD 2808, and on the initial profile dated 12 September 2006.  The CI did note that she used a cane for her knees on the DD 2807-1 though.  Standing (weight bearing X-rays) on 14 March 2007 showed minimal joint space narrowing, but no sclerosis or degenerative joint disease (arthritis).  However, MRIs of the knees obtained on 19 March 2007, while in the MEB process were unremarkable bilaterally other than a small joint effusion.  On 3 April 2007 at the orthopedics examination, the CI was observed to have normal pain free motion.  One week later a different orthopedist noted that there was no significant pathology of the knees.  The ROM was a full 140 degree arc, but from (-) 5 to 135 degrees rather than the VA normal 0-140 degree arc.  As this was symmetric, it is most likely a normal variant for this individual.  As noted above, the CI had a normal gait at presentation for the gynecology C&P examination 3 months after separation.  

At the VA C&P evaluation on 10 October 2008, 12 months after separation, the CI reported that her bilateral knee pain began in 2004 after she missed a step on an incline on a run in advanced training (AIT).  On examination, her gait and strength were normal and atrophy was absent.  Motion was full (0-140), but painful.  Laxity was absent as were other joint abnormalities.  X-rays were not repeated.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing pain, slight and frequent.  The VA did not initially service connect either knee condition, analogously coded 5299-5260 (leg limitation of flexion) based on the service treatment record, citing no medical evidence of a chronic knee condition for both the right and left knee.  However, a subsequent decision after the C&P examination rated each knee at 10% for painful extension, coded 5099-5024 (tenosynovitis).  The rater noted painful and limited motion even though the motion was actually full.  The panel considered the evidence.  There was no imaging evidence of arthritis, ligamentous damage, or cartilage degeneration.  The ROM was normal on all examinations but one which actually had a full range, but to different end points that the VA standard.  An effusion was noted bilaterally on the MRIs, but this was small and a treating orthopedist determined that there was no significant pathology evident.  Regardless, even if this were conceded as indicative of possible arthritis, it would support a rating of no more than 10% and this would be under the 5003 code utilized by the PEB.  The panel found no route to a higher rating than that adjudicated by the PEB and opined that the bilateral 10% ratings adjudicated by the VA were not supported in the STR or on the VA 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 bilateral knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic LBP and chronic bilateral knee pain conditions 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 20150908, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170013345, 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