RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00545
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Laundry & Textile Specialist, medically separated for “chronic back pain” and “chronic pain, left knee,” rated at 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “I am 30% disable from VA.  Lots of migraines and vision issues since.  I contested this rating of 10% severance then.”  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 conditions 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 - 20040610	VARD - 20040918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	L4/5 Annular Bulge Spinal Stenosis, Thoracolumbar Spine	5238	10%	20040622	
Chronic Pain, Left Knee	5099-5003	0%	Retropatella Pain Syndrome, Left Knee	5260	10%		
Post Concussive Headaches	Not Unfitting	Post Concussive Syndrome with Headaches	9304-8100	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2003 after a motor vehicle accident (MVA).  X-ray studies in August 2003 were normal a December 2003 MRI showed an L4-L5 annular bulge causing mild spinal canal and right/left foraminal stenosis.  

At the 26 January 2004 physical therapy (PT) clinic appointment, 7 months before separation, the CI had no complaints of numbness.  The examiner recorded range of motion (ROM) measurements with flexion at 75% (estimated 65 degrees of normal 90), extension at 50% (estimated 15 degrees of normal 30), side bending at 75% (estimated 25 degrees of normal 30), and normal rotation of 30 degrees (estimated combined 190 degrees of normal 240).  The examiner documented painful motion and decreased sensation over the left lateral aspect of the entire leg, and noted “inconsistencies with testing, subjective greater than objective.”  The CI had an antalgic gait with a standard cane.  

At the 8 March 2004 PT clinic appointment, 6 months prior to separation, the CI reported mid back pain, rated at 7/10 and worsened with prolong standing and walking.  Physical examination showed normal strength, some pain with left greater than right straight leg raise (SLR) testing, and “a significant amount of paraspinal muscle spasm throughout the lumbar L5-S1.”  There were no documented ROM measurements or gait abnormalities.  

The 17 May 2004 MEB NARSUM examination, 4 months before separation, noted CI complaints of low back pain.  Physical examination showed ROM measurements with flexion to 45 degrees, and a combined ROM of 155 degrees.  Motor, strength, sensory and reflex testing was normal with SLR testing negative for radiculopathy.  The examiner documented 2 out of 4 positive Waddell signs (non-physiologic findings), and that the CI’s antalgic gait was due to knee pain.  X-ray studies in April 2004 were normal.  

At the 22 June 2004 VA Compensation and Pension (C&P) evaluation, 2 months prior to separation, the CI reported constant mid to low back pain with no incapacitating episodes.  Physical examination revealed a normal gait, no complaints of radiating pain on movement, and no muscle spasms.  Tenderness was noted at L4 and SLR testing was negative for radiculopathy.  ROM measurements showed flexion to 70 degrees and a combined ROM of 200 degrees, limited by pain.  There was no additional loss of motion limited by fatigue, weakness, lack of endurance, and incoordination.  The examiner found no ankylosis or signs of intervertebral disc syndrome and recorded normal strength and reflexes.  X-ray findings were within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing no neurologic abnormality and combined thoracolumbar ROM of 170 degrees.  The VA also rated the back condition 10%, coded 5238 (spinal stenosis), citing limitation of forward flexion and combined ROM.  The panel adjudged that the C&P evaluation was closest to separation, included repetitive motion, and therefore had the highest probative value for rating.  Members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees).  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.  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 back pain condition.  

Chronic Pain, Left Knee.  According to the STR and the MEB NARSUM, the CI’s knee condition began in July 2003 after an MVA.  X-ray studies in August 2003 were normal.  At an 8 October 2003 primary care visit, the CI complained of left knee pain.  The examiner noted a limping gait and pain with full ROM.  There was no effusion, erythema, or ecchymosis; and no meniscal finding, laxity or instability.  At an 8 March 2004 PT visit, the examiner observed a normal gait and strength but a significant amount of pain with left knee ROM (no measurements recorded). 

The 17 May 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of left knee pain and that the CI occasionally used a cane to assist with ambulation.  Physical examination revealed an antalgic gait and a positive patellofemoral grind test. ROM measurements showed flexion to 90 degrees (normal 140) and extension to 0 degrees (normal).  There was no joint line tenderness or ligamentous laxity.  

At the 22 June 2004 C&P evaluation, 2 months before separation, the CI reported constant left knee pain (with no incapacitating episodes) and the inability to lift heavy objects or walk, sit, and stand for prolonged periods.  Physical examination showed ROM measurements with flexion to 90 degrees, not limited by pain, fatigue, weakness, lack of endurance, or incoordination.  Crepitus was noted but laxity and meniscal testing were negative.  X-ray studies were within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy for minimal/frequent pain.  The VA rated the left knee condition 10%, coded 5260 (leg, limitation of flexion), based on the STR and pre-separation C&P examination, citing pain on motion.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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 no fracture, 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 left knee condition, coded 5099-5003.  

Contended PEB Condition:  Post Concussive Headaches.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended post concussive headache condition was not unfitting.  The CI submitted rebuttals to the PEB contending “post concussive syndrome;” however only the post concussive headache condition is within scope for the PDBR.  The contended post concussive headache condition was profiled and judged to fail retention standards; however, it was not implicated in the commander’s statement.  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 chronic back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left knee pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended post concussive headaches 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 recommends 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 Back Pain	5299-5237	10%	
Chronic Pain, Left Knee	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160904, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170016251, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,	
Enclosure