RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00709
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Light Wheeled Vehicle Mechanic, medically separated for “bilateral knee pain” with a disability rating of 0%.  

CI CONTENTION:  “Review all 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 - 20040205	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Anterior Knee Pain	5099-5003	0%	No VA examination in evidence 
	
Chronic Mid and Low Back Pain	Not Unfitting		
Adjustment Disorder with Depressed Mood	Not Unfitting 
		
Personality Disorder Not Otherwise  Specified	Not Unfitting 
		
Recurrent Chest Wall Pain	Not Unfitting 
		
Vision Defect	Not Unfitting 
		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA 	

ANALYSIS SUMMARY:  

Chronic Bilateral Anterior Knee Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s knee condition began during Advanced Individual Training in 1993.  At that time, the pain was characterized as “slight.”  In 1995, the CI reported chronic knee pain related to the physical fitness runs.  The CI was placed on a permanent L2 profile for running.  In 1996 his knee pain worsened following a motor vehicle accident when his knees struck the dashboard.  He was placed on a temporary profile and eventually his knees returned to prior baseline.  In 1997, the knee pain worsened without improvement and the CI was put on a permanent L3 profile.  The CI requested a change to his military occupational specialty (MOS) which resulted in his profile being changed back to an L2 to facilitate the administrative process.  In August 2000, the knee pain continued.  On 11 March 2003, X-rays of the bilateral knees were normal.  On 23 July 2003, the CI was not improving and was again continued on a P3 profile.  

The 21 November 2003 MEB NARSUM examination, 4 months prior to separation, noted complaints of bilateral knee pain where the CI was unable to run at all or walk greater than three to five miles on a level surface.  Physical examination noted no effusion, erythema or increased temperature.  Range of motion (ROM) was 130 degrees (normal 140) bilaterally without tenderness.  Tests for laxity (Lachman’s, drawer and pivot shift) were negative for anterior cruciate ligament injury or laxity nor was there was laxity with varus or valgus stress testing.  However, he was markedly tender behind the patellofemoral joint, otherwise the bilateral knee examination was normal.  

The 20 January 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of not being able to tolerate prolonged standing, heavy lifting, squatting, or getting into awkward positions.  The CI was not able to run, jump, or march.  Physical examination showed bilateral tenderness to pressure in the peripatellar area and along the lateral joint lines.  The grind test and McMurray’s test (to determine a meniscal tear) were positive bilaterally.  No effusion was noted and there was no laxity.  ROM was 154 degrees bilaterally.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (arthritis, degenerative), citing no loss of joint motion or evidence of instability.  The PEB combined the right and left knee conditions as a single unfitting condition coded 5003 (arthritis) rated 0%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left knee conditions were presented together as all examinations reported the condition together.  

As noted above, there are no distinctions with regard to clinical features or fitness considerations between the right and left knee as presented in the NARSUMs.  The bilateral diagnosis supported a single 5003-based rating for “two or more major joints” without significant ROM limitations or painful motion, thus there is VASRD §4.71a latitude for a bilateral rating.  Panel members agreed, therefore, that the evidence did not support recommending separate right and left knee disability ratings.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 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), or history of surgery to remove a meniscus (5259) to support a rating under those respective 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).  No additional functional limitation was evidenced by the examinations.  Therefore the panel concluded there was insufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

Contended PEB Conditions:  Chronic Mid and Low Back Pain, Adjustment Disorder with Depressed Mood, Personality Disorder Not Otherwise Specified, Recurrent Chest Wall Pain, and Vision Defect.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Chronic back pain was profiled and addressed in the commander’s statement, but was adjudicated to meet retention standards by the MEB.  The mental health condition was not profiled, but the commander’s statement indicated the CI’s mental condition was diagnosed as manic-depressive with a general anxiety disorder since 1996.  The medication he was prescribed restricted his ability to work around heavy machinery as a mechanic. The recurrent chest wall pain was neither profiled nor mentioned in the commander’s statement and was found to meet retention standards.  The vision defect required an E2 profile, was not mentioned in the commander’s statement, and was found to meet retention standards.

Chronic Mid and Low Back Pain.  A note dated 14 May 2003 indicated the CI had some tension in the lower lumbar areas on occasion depending on the position the he slept in.  The back examination was essentially normal.  Straight leg raise testing (to determine nerve root irritation) was negative bilaterally and there was excellent strength and symmetry of major muscle groups of the lower extremity.  On 6 June 2003 the CI complained of upper back pain for a month after wearing a flak jacket and load-bearing equipment.  Examination revealed a supple neck and no spasm.  There was full ROM and the CI was minimally tender at the trapezius. The CI underwent chiropractic evaluation and was noted to have cervical and lumbar segmental dysfunction on 10 June 2003.  

On 23 July 2003 the CI a note indicated the CI had full ROM of the back without spasm.  The 21 November 2003 MEB NARSUM noted complaints of low back pain without radiation for 1 year, which began when the CI was struck in the back by a generator dropped by another soldier.  Physical examination showed the CI had an antalgic gait.  He was able to forward flex to 10 inches from the floor or 80 degrees.  Extension was 20 degrees and there was right and left bending at 35 degrees each.  He was able to walk on both heels and toes without difficulty.  He had no foot drop and had 5/5 muscle strength in the bilateral lower extremities.  Neurologic evaluation was unremarkable.  

During the 24 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported low back pain.  Physical examination showed tenderness from T12 to L4 without palpable spasm or visible deformity.  The examiner used abbreviations that were not standard for ROM measurements.  Therefore, active forward flexion presumably was 70 degrees (normal 90) with pain beginning at 55 degrees and the combined ROM presumably was 210 degrees.  However, the ROM was noted to be mildly decreased in the 20 January 2004 NARSUM which was based on the 24 November 2003 MEB examination.  At the remote VA Compensation and Pension (C&P) spine evaluation, 15 months post-separation, his ROM measurements were normal and motions were performed without difficulty and without palpable or visible spasms.

Adjustment Disorder with Depressed Mood and Personality Disorder Not Otherwise Specified.  The 7 January 2004 Psychiatry MEB Consultation Addendum, 4 months prior to separation, indicated the CI first presented in February 2002 with complaints of frustration, problems dealing with stress, and complaints of being “tired of getting screwed.”  He was diagnosed as having an adjustment disorder with an anxious mood.  He attended five sessions of the Healthy Living group until April 2002.  He received care for comments he made to his commanders, but stated to mental health personnel that he had no intention of killing himself but instead had made comments for the purpose of dramatizing how frustrated and stressed he had been.  He was treated with an antidepressant (Effexor), but he tried to transfer by telling a clinician he was on the brink of getting into a physical altercation.  He reported benefit from clonazepam (for anxiety) once or twice per week and he enjoyed his job.  He had not been seen in follow-up after mid-November 2003.  

On mental status examination the CI was alert and controlled.  He displayed good eye contact and attention and was euthymic.  His thoughts at times were vague, but he was organized, goal-directed, and logical.  He was not suicidal but consistently self-absorbed and exhibited no indication of any thought disorder.  The examiner’s diagnoses were adjustment disorder with depressed mood, acute, manifested by the development of emotional or behavior symptoms in response to an identifiable stressor and personality disorder NOS with narcissistic traits.  He had a Global Assessment of Functioning (GAF) score of 70 (some mild symptoms or some difficulty in social, occupational, or school function, but generally functioning pretty well, has some interpersonal relationships).  The examiner noted the CI appeared to have experienced distress and difficulty coping with what he viewed as an untenable work situation.  His symptoms appeared to have remitted with change in his work situation, whereupon he ceased contact with mental health providers.  His psychiatric conditions were deemed to be not unfitting for military duty.

Recurrent Chest Wall Pain.  Apparently the CI injured his chest wall playing football.  X-rays were negative in 2001 and again in 2003.  A note dated 6 June 2003 indicated the CI’s sternum was minimally tender.  At a chiropractic evaluation the CI was noted to have costochondritis, which was attributed to right-sided rib dislocations.  He did get occasional chest pain when he ran due to the work of breathing, but denied any wheezing.  

Vision Defect.  In August 2003 the CI requested to participate in the “Warfighter” Photorefractive Keratectomy. The CI had myopia bilaterally, which was corrected with glasses.

The panel majority determined there was no performance-based evidence from the record that any of the contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS: In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended chronic mid and low back pain, adjustment disorder with depressed mood, personality disorder NOS, recurrent chest wall pain, and vision defect conditions, the panel majority recommends no change from the PEB determinations as not unfitting.  The single voter for dissent submitted the appended minority opinion for the contended chronic mid and low back pain.  There are no other conditions within the panel’s scope of review for consideration.  The pane majority, therefore, recommends 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 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

	

Minority Opinion.  It is patently obvious the CI was unfit for duty as a light wheeled vehicle mechanic as a result of chronic mid and lower back pain.  Not only did the CI’s duties include supervising and performing unit maintenance and recovery operations on gasoline and diesel fueled light-wheel vehicles (prime movers designated as 5 ton or less and their associated trailers) and associated items, but also supervising unit maintenance and recovery operations on track and heavy-wheel vehicles, and on material handling equipment.  The physical demands rating is very heavy.  The commander’s statement is perfectly clear and unequivocal:  “As a soldier, his duties in a worldwide field environment will require him to wear tactical equipment and lift heavy material.”  Furthermore, his profile listed chronic back pain which precluded wearing a backpack and limited lifting to up to 30 pounds, running, squatting, and bending, thereby providing more than sufficient preponderance of evidence that the CI was not fit to perform the duties of his MOS.  

While still on active duty the CI had limited ROMs for flexion of approximately 80 degrees and presumably 70 degrees with pain beginning at 55 degrees as recorded on DD Form 2808.  However, neither examination was in accord with VA guidelines since the former was based on forward flexion to the floor measured in inches and the latter measurement was recorded using an unclear abbreviation format, which was noted to be mildly decreased in the NARSUM.  Nevertheless, prior to separation the CI had significant chronic back pain such that he was unable to perform his very physically demanding MOS duties.  The fact that the ROM measurements were normal 15 months post-separation speaks clearly that without the physical demands of the job healing occurred.  

Therefore, the minority voter recommends the PDBR find the CI unfit for chronic mid and low back pain since the preponderance of evidence with regard to the functional impairment of the mid and low back favors its recommendation as an additionally unfitting condition for disability rating.  A 10% rating, but no higher, is justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported on the 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.  Therefore, the chronic mid and low back pain is appropriately coded 5237 and meets the VASRD §4.71a criteria for a 10% rating.  

The minority voter recommends the ROP be modified as follows:

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 Bilateral Anterior Knee Pain	5099-5003	0%	
Chronic Mid and Low Back Pain	5237	10%	
COMBINED	10%	

 

AR20170017451, 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 record of proceedings and majority recommendation and minority opinion (copy enclosed).  I reject the Board’s majority recommendation and accept the Board’s minority opinion that your disability rating should be modified to 10% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  

	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