RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01080
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041102

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, STACOM Systems Operation Maintainer, medically separated for “low back pain” and “bilateral knee pain,” rated 10% and 0%, respectfully, with a combined disability rating of 10%.

CI CONTENTION:  Review of all conditions.  Exhibit A is the complete submission.

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 - 20040706	VARD - 20050128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Residual of Low Back Injury	5237	10%	20040813	
Bilateral Retropatellar Pain Syndrome	5099-5003	0%	Right Knee Retropatellar Pain Syndrome	5099-5024	10%	20040813	
			Left Knee Retropatellar Pain Syndrome with Osteochondroma	5099-5024	10%	20440813	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in 2002 after a fall, brief loss of consciousness, and was evaluated for a spine injury with possible paralysis.  No fracture was identified.

The 11 May 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of continued back pain.  Physical examination revealed the ability to heel and toe walk.  There was spinal tenderness but no muscle spasm.  Straight leg raise test (for radiculopathy) was negative.  Waddell’s sign (inappropriate response to spinal pain or tenderness) was 2/5.  Inclinometer measured range of motion (ROM) showed flexion to 65 degrees (normal 90) and combined ROM was 195 degrees (normal 240); painful motion was present in all planes.  During the 6 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, physical examination showed pain to the neck and lower back with pain on motion.  Measurements were not addressed.

At the 13 August 2004 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported stiffness, difficulty performing his military duties and difficulty running, lifting, bending, and walking up and down stairs.  Physical examination showed an abnormal gait as the CI favored his left knee.  The CI was able to heel/toe and tandem walk.  Spinal contour was normal without muscle spasms.  Deep tendon reflexes were 2+ bilateral.  Sensory was two point discrimination sharp/dull.  Straight leg raise testing was negative. Musculoskeletal strength was 5/5.  Thoracolumbar ROM showed flexion to 80 degrees and combined ROM was 185 degrees; ROM was limited by pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 10%, coded 5237 (lumbosacral strain), citing forward flexion at 85 degrees.  The VA also rated the back condition 10%, coded 5237, (lumbosacral strain), based on the C&P examination 3 months before separation, citing decreased ROM with painful motion.  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) as reported on the MEB NARSUM and VA examinations proximate to 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.  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 back condition.

Bilateral Retropatellar Pain Syndrome.  The PEB combined the bilateral knee pain conditions as a single unfitting condition coded analogously to 5099-5003(analogous to arthritis, degenerative) and rated 0%.  The 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’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 bilateral knee pain condition is presented with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the STR and the MEB NARSUM, on 1 May 2003 the CI’s underwent a resection of an osteochondroma at the medial aspect of the distal left femur.  After the surgery, the CI’s knee felt unstable with walking or running.  On 14 April 2004, X-rays showed left tibia and left fibula proximal metaphyseal osteochondroma.  The 11 May 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of knee instability on walking or running.  Physical examination showed positive bilateral patellofemoral grind with tenderness over the patellar tendon on the left side.  No joint effusion or crepitus were noted.  Bilateral ligamentous laxity and meniscus testing were negative.  Right knee ROM was flexion to 105 degrees (normal 140) and extension to 0 degrees (normal 0).  Left knee flexion was 80 degrees and extension was -5 degrees; painful motion was only noted for the left knee.

At the 13 August 2004 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported bilateral knee pain with prolonged sitting, standing, and utilizing stairs.  Physical examination showed an abnormal gait.  There was no knee crepitus, erythema, warmth, or edema.  Bilateral ligamentous laxity and meniscus testing were negative.  Left knee flexion was 107 degrees and extension 0 degrees.  Right knee ROM was reported as “normal.”  Painful motion was only noted for the left knee.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing normal ROM and no ligamentous laxity.  The VA rated each knee separately 10%, analogously coded 5099-5024 (tenosynovitis), based on the C&P examination 3 months before separation, citing right knee painful motion and left knee decreased painful motion.

The panel first considered if the right knee and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Each knee was permanently L3 profiled as “knee pain”.  Both knees were jointly implicated by the commander’s performance statement which noted the L3 profile limitations which adversely affected the CI’s ability to perform his military specialty’s physical tasks and basic soldier skills. The MEB Report judged the CI’s bilateral knee condition to fail retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled right knee and left knee conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right knee and the unfitting left knee conditions at the time of separation.

There was no limitation of flexion or extension of either knee that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under these respective codes for either knee.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The left knee osteochondroma was part of the underlying cause of the CI’s pain and not a separately ratable condition.  The panel noted that both knees had decreased non-compensable ROM but only the left was limited by pain as documented by the MEB NARSUM and C&P examinations.  The panel agreed a 10% rating for the left knee was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion); but was not supported for the right knee.  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings for each knee.  The panel noted that “bundling,” the combining of two or more major joints, is 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 determined a combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 bilateral knee condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral retropatellar pain syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends that 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 Low Back Pain	5237	10%	
Bilateral Retropatellar Pain Syndrome	5099-5003	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

AR20170018541, 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