RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00287
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20081221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Construction Equipment Repair, medically separated for “arthritis due to trauma, right knee,” “chronic lumbar back pain,” and “neuralgia of the plantar (sural) nerve [right],” with a combined disability rating of 10%.

CI CONTENTION:  The CI contends high blood pressure.  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 - 20080915	VARD - 20140903	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis…Right Knee	5010	10%	Right Knee, Stable Joint Arthritis	5260-5003	10%	20140722	
			Right Knee, Surgical Scar	7805	0%	20140722	
Chronic Lumbar Back Pain	5299-5237	10%	Low Back Pain	5237	NSC	20140722	
Neuralgia, Plantar (Sural) Nerve [Right]	8727	0%	Right Foot Numbness associated with Right Knee Stable Joint	8520	NSC	20140722	
Hypertension	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Arthritis Due to Trauma, Right Knee.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in March 2006 when he felt a pop in his knee during a company run.  Right knee magnetic resonance imaging performed on 8 July 2006 showed an osteochondral defect in the medial femoral condyle (MFC).  The CI subsequently underwent arthroscopic debridement in July 2006 with a post-operative diagnosis of MFC chondromalacia.  Due to continued MFC symptoms, a second surgery for tibial osteotomy was performed in September 2007.  Repeat MRI on 3 June 2008 showed no new lesions or abnormalities and was consistent with post-operative healing of the cartilage and bone graft.  

The 5 August 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of right knee pain, locking and popping, instability and giving way.  The CI reported flare-ups three time per week lasting approximately 30 minutes, requiring rest ice, elevation, and stretching.  Physical examination showed an antalgic gait favoring the right lower extremity.  There was a well healed surgical scar on the right knee with “minimal” scar numbness and paresthesias with percussion (Tinel’s sign).  There was tenderness to palpation (TTP) of the knee at the edge of the surgical hardware and crepitus with range of motion (ROM).  There was no patellofemoral crepitus and there was no evidence of instability or meniscal injury.  Right knee ROM was extension 0 degrees and flexion 113 degrees, with pain and progressive decrease in ROM with repetition was noted, but not quantified.  The ROM findings were essentially the same for the left knee.  The CI could “easily” squat and rise without difficulty or use of his upper extremities. 

The 22 July 2014 VA Compensation and Pension (C&P) examination, almost 6 years after separation, the CI reported constant right knee pain without flare-ups.  He had not received care at any facility after separation from the military.  He reported being evaluated for a few days of increased knee pain secondary to his occupation as a cook on 27 May 2009.  There was no additional history since May 2009.  Right knee ROM was extension 0 degrees and flexion 135 degrees without objective evidence of painful motion.  There was no additional loss of ROM with repetition.  There was no TTP.  There was no evidence of instability or meniscal injury.  X-rays showed post-surgical changes with intact hardware and minimal degenerative changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5010 (traumatic arthritis), citing painful, limited motion.  The VA also rated the right knee condition 10% coded 5260-5003 (limitation of leg flexion-degenerative arthritis), based on the C&P examination almost 6 years after separation, citing degenerative arthritis and limitation of motion.  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.  The initial VA C&P examination performed was well beyond the panel’s normal 12 month window for consideration, but provides long term information that supports that the status of the right knee condition was stable at separation.  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).  There was no history or evidence 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 those codes.  There was surgical removal of tibial bone performed, however, there was nonunion or malunion 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.  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.

Chronic Lumbar Back Pain.  According to STR and the MEB NARSUM, the CI’s low back condition began in September 2007 after resuming physical therapy following right knee surgery.  The CI reported the gradual onset of low back pain (LBP) without radicular symptoms.  Lumbar spine X-rays performed were normal.  During the MEB examination, the CI was referred to physical medicine and rehabilitation (PM&R) for further evaluation.  The PM&R examination on 01 August 2008, 5 months prior to separation, recommended that the CI continue his MEB with the low back condition included.  Lumbar spine MRI performed on 6 August 2008 was normal.  

The 5 August 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of intermittent LBP located in the center of the back.  The pain was exacerbated by activity and relieved by rest.  The CI denied muscle spasms or weakness.  Physical examination showed an antalgic gait related to the right knee.  There was no voluntary guarding.  There was minimal tenderness and muscle spasm noted over the lower lumbar spine.  Thoracolumbar ROM was flexion 96 degrees (normal 90) and combined ROM of 220 degrees (normal 240), with painful motion noted and there was minimal decrease in ROM with repetition.  The CI could easily squat and rise without difficulty or use of his upper extremities.  Lower extremity strength, sensation, and reflexes were normal and straight leg raise testing to elicit nerve tension signs was negative bilaterally.  

As noted above the 22 July 2014 VA Compensation and Pension (C&P) examination, almost 6 years after separation, indicated the CI reported no treatment of the low back condition after separation from the military, but the examiner noted he was diagnosed with degenerative disc disease without radiculopathy in 2014.  The CI reported constant low back pain without flare-ups.  Thoracolumbar ROM was flexion 90 degrees and combined ROM of 230 degrees without objective evidence of painful motion.  There was no additional limitation of motion with repetition.  There was no tenderness to palpation or guarding and there was no muscle spasm resulting in an abnormal gait or an abnormal spinal contour.  Lower extremity strength, sensation, and reflexes were normal and SLR was negative.  The VA examiner indicated the CI did not have intervertebral disc syndrome of the TL spine.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded analogously to 5237 (lumbosacral strain), citing localized tenderness.  The VA did not service connect the low back condition, citing that the medical evidence supports the conclusion that a persistent disability was not present in service.  
The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB NARSUM examination.  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.  Muscle spasm was noted at the MEB NARSUM examination, however, it was noted to be “minimal” and the CI’s antalgic gait was noted to be related to the right knee condition, thus the next higher 20% rating was not justified on this basis.  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 condition.

Neuralgia of the Plantar (Sural) Nerve.  According to STR and the MEB NARSUM, the CI’s right lower extremity neuralgia condition began after receiving right knee surgery in September 2007.  The CI reported numbness and paresthesias to the inner aspect of the lower leg and indicated the CI was treated for neurogenic pain.  Notes in the STR indicate that the CI was referred to podiatry twice in February and July 2008 for reported numbness of the inner aspect of the right foot and great toe.  There were no podiatry visits in record.  Right foot X-rays performed 12 February 2008 were normal except for “suggestion” of a hallux valgus deformity.  

At the 1 July 2008 MEB examination (recorded on DD Forms 2807 and 2808), 6 months prior to separation, the CI reported numbness and tingling of the right knee and foot since surgery, with pain and cramping of the right foot.  Physical examination showed a normal foot arch and “asymptomatic” was circled.  The 05 August 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of right knee pain and tingling.  The CI reported numbness over the anterior aspect of the right knee over the leg to the top of the foot.  Further examination showed lower extremity sensation was intact, but there was minimal scar numbness and paresthesias upon percussion.  Lower extremity strength, reflexes, and pulses were normal.  

As noted above the 22 July 2014 VA Compensation and Pension (C&P) examination, indicated the CI reported no medical treatment since separation.  Examination did not address a foot condition.  However, the examinations of the knee and back noted no weakness or sensory deficits of the lower extremity.  The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neuralgia condition 0%, coded 8727 (internal saphenous nerve-ISN).  The VA did not service connect a claim for numbness of the right foot related to the right knee surgery, based on the VA examination almost 6 years after separation, citing no current evidence of a diagnosis. The PEB utilized the VASRD nerve code for the ISN, which supplies sensation to the medial aspect of the leg to the foot and appeared to the panel to be a good fit with the CI’s nerve related symptoms.  There was no evidence of severe or complete incomplete paralysis of the ISN for a higher rating than 0% with this code.  Alternative VASRD peripheral nerve codes, were less applicable or not advantageous to 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 neuralgia condition.

Contended PEB Conditions:  Hypertension.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel 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 arthritis due to trauma, right knee and the chronic lumbar back pain conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications.  In the matter of the neuralgia of the plantar nerve IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudications.  In the matter of the contended hypertension condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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 20160414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015252, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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