RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01064
BRANCH OF SERVICE:  army		SEPARATION DATE:  20040623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Visual/Audio Equipment Repairer, medically separated for “chondromalacia of the right knee” with a disability rating of 10%.  “Chronic back pain” was determined to have existed prior to service (EPTS) and not rated. 

CI CONTENTION:  A lengthy contention regarding back and foot conditions was provided.  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 -  20040315	VARD - 20040908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia, Right Knee	5099-5003	0%	Chondromalacia Right Knee	5099-5010	10%	20040610	
Chronic Back Pain	5237	---%	Degenerative Disease Lumbar Spine	5242	10%	20040610	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Chondromalacia of the 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 1996 after a fall from repelling during basic training, and worsened during advanced individual training.  The CI subsequently struck his knee while playing sports, and an April 2002 MRI revealed a horizontal tear at the periphery of the posterior body and posterior horn of the medial meniscus, and grade IV chondromalacia (runner’s knee) of the medial patella.  He was evaluated by orthopedics and surgery was not recommended.
During the 19 November 2003 MEB NARSUM examination, 7 months prior to separation, the CI reported chronic right knee pain aggravated by walking and running.  Physical examination showed normal knee alignment and patellar tracking.  There was severe pain and crepitus with compression of the patellofemoral joint.  Range of motion (ROM) was documented as “full” and painful motion was not cited.

At the 10 June 2004 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported right knee pain aggravated by prolonged walking, standing, running or jogging.  Physical examination revealed a normal gait without a device for assistance.  There was knee tenderness on patellar compression.  Both instability and meniscus testing were negative.  ROM was 0-135 degrees (normal 0-140) with painful motion.  There was no further limitation due to incoordination, weakness or flare-up.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing knee tenderness.  The VA rated the right knee condition 10%, analogously coded 5099-5010 (arthritis due to trauma), based on the C&P evaluation 2 weeks before separation, citing X-ray evidence of arthritis and limitation of motion.  The panel agreed 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) documented by the comprehensive C&P evaluation.  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 right knee condition, coded 5099-5003.

Chronic Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition began prior to service at age 14, and was documented on the CI’s 1996 service entry examination; however, the CI did not seek medical attention and there was no evidence of a service entry waiver.  In July 2000, the CI sought care for recurrent back pain with flare-ups. February 2002 X-rays revealed minimal L5-S1 intervertebral disk space narrowing.  At a 12 January 2003 primary care clinic appointment, the CI reported back pain after moving unit furniture and computers.  Physical examination noted L4-L5 tenderness and limited flexion.  Medications were prescribed, a profile was issued and an orthopedics referral was initiated.  The 24 January 2003 Report of Medical Assessment (DD Form 2697), documented the CI’s military specialty and White House Communication Agency assignment, which required him to frequently lift equipment weighing over 200-350 pounds (an armored podium was cited as an example). The CI also stated he was required to carry numerous pieces of equipment when on temporary duty for presidential missions.  A 21 October 2003 MRI revealed a left L4-5 herniated disc.  

During the 19 November 2003 MEB NARSUM examination, 7 months prior to separation, the CI reported chronic back pain with occasional flares, and intermittent radiation to his buttocks, but not down to the legs.  Physical examination revealed no spinal tenderness.  ROM was “full” and painful motion was not addressed.  The 31 December 2003 commander’s statement documented the CI’s requirement to lift heavy equipment, bend over extensively, stand for prolonged periods, and perform these tasks during worldwide deployments.

At the 10 June 2004 VA Compensation and Pension (C&P) joint evaluation, 2 weeks before separation, the CI reported his back pain started as a teenager.  He subsequently joined the military, and over the years, lifting heavy material and exercising aggravated his back pain; he denied any specific pre-existing aggravating episode.  Physical examination showed a normal gait and posture with no spinal tenderness or muscle spasm.  ROM was flexion to 80 degrees (normal 90) with a combined ROM of 195 degrees (normal 240); painful motion was not addressed.  There was no evidence of further limitation on repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the back pain to be an EPTS condition that was not permanently service aggravated (service time was 7 years and 8 months), analogously coded 5099-5003, citing natural progression.  The VA rated the back pain condition 10%, coded 5242, (degenerative arthritis of the spine), based on the C&P examination 2 weeks before separation, citing limitation of flexion.  The panel first considered whether the CI’s back condition existed prior to service and was permanently service aggravated, and agreed that STR documentation provided evidence for both.  Although the CI reported pre-existing back pain which was documented upon service entry in 1996, the physical evaluation was negative for a back condition.  The CI did not seek medical attention for his back until July 2000.  Additionally the commander’s statement and other STR entries showed that the CI’s military specialty required him to lift heavy equipment, bend over extensively, stand for prolonged periods, and perform physical training and basic soldiering maneuvers that permanently service aggravated his back pain.  The panel determined that the presumption of service aggravation was not overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of the CI’s military service.

The panel then considered its rating recommendation for the unfitting back condition at the time of separation.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) documented by the VA examination, which was considered the most comprehensive and of highest probative value at 2 weeks before separation.  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.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence, the panel concluded the back condition was permanently service aggravated and recommends a disability rating of 10%, coded 5237 (lumbosacral strain).

BOARD FINDINGS:  In the matter of the chondromalacia of the right knee condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the chronic back pain condition, the panel unanimously concluded there was permanent service aggravation and recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  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	
Chondromalacia of the Right Knee	5099-5003	10%	
Chronic Back Pain	5237	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20170018605, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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