RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01248
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040409 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistics Specialist, medically separated for “low back pain” and “bilateral knee pain,” rated 10% and 0%, respectively with a combined disability rating of 10%.  The “chronic neck pain” condition which was determined to have existed prior to service (EPTS) and was not rated.  

CI CONTENTION:  The CI’s conditions continue to worsen.  The complete submission is 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 - 20031112	VARD - 20040506 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5237	10%	Mechanical Low Back Pain	5299-5237	NSC	20040105	
Chronic Bilateral Knee Pain	5099- 5003	0%	Right Knee Chondromalacia	5099-5019	10%	20040105	
			Left Knee Chondromalacia	5099-5019	10%	20040105	
Chronic Neck Pain Secondary to Vertebrae Plana And Neuro-foraminal Narrowing at C3-C7	5003	---%	Cervical Spine Stenosis	5299-5238	10%	20040105	
Wrist Pain Right and Left	Not Unfitting	Right Wrist Tendonitis	5024	10%	20040105	
		Left Wrist Tendonitis	5099-5024	10%	20040105	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI noted the onset of low back pain during basic training with increased physical activities required at basic and advanced training.  Low back X-rays revealed no gross pathology and bone scan of the total body showed no increased uptake at the lumbosacral spine, sacroiliac joints or the hip.  There was no suspicion for ankylosing spondylitis or other active bony disease.  There was no surgical indication.  

At the 11 July 2003 MEB NARSUM examination, 9 months prior to separation, physical examination showed a normal gait.  There was muscle spasm and relatively straight somewhat flattened lordotic lumbar curve.  There was a slight scoliotic curve concave to the right.  The examination documented trunk flexion as the ability to reach the finger tips within 60 cm (23.6 in) of the floor which approximates 20-30 degrees of thoracolumbar flexion.  

At the 5 January 2004 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported constant low back pain located in his thoracic and lumbar spine on the left.  He reported pain was aggravated by lifting or bending.  He also stated that he could not sit up straight, he must lean or lie forward.  Physical examination showed a normal posture and gait with no abnormal contours.  Thoracolumbar range of motion (ROM) measurements showed flexion of 90 degrees (normal) and combined ROM of 200 degrees (normal 240) after repetition.  During repetitive motion, there was significant pain expressed.  When the CI was lying supine on examination, he was asked “where he got the scar on his left knee and he instantaneously flexed into the almost prenatal position to explain about his childhood injury.  Shortly thereafter, he expressed pain on all joint evaluations that appeared to be out of proportion to the examination being done on him.”  The CI was able to reach within four inches of the floor with his fingertips.  There was tenderness over the lumbar spine, and there were no paraspinal muscle spasms.  At a 4 January 2005 VA General Medicine visit, 9 months after separation, the CI reported that his physical complaints were resolved, he stated that he had these problems while in Saudi Arabia.  Physical examination showed no spinal tenderness, the remainder of the back examination was deferred.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbar spine strain), citing pain on motion.  The VA did not service-connect the LBP condition, based on the C&P examination 3 months before separation, citing no permanent residual or chronic disability subject to service connection was shown by the STR or demonstrated by VA examination.  The panel considered the probative value of the examinations proximate to separation.  The MEB NARSUM examination was not reported as goniometric measurements and the length of various body parts could result in a wide array of interpretations of that evaluation.  The C&P examination proximate to separation was more detailed and reported ROM performed after repetitive motion.  Therefore, the panel placed greater probative value on the VA examination.  

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 VA examination proximate to separation.  Although there was muscle spasm and an abnormal contour recorded on one examination, that examination was assigned lesser probative value than the C&P examination for the reasons listed above.  During the other examinations in evidence the preponderance of the evidence shows there was no muscle spasm 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 (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  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 LBP condition.  

Chronic Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and 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 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 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 adjudicated by the PEB.  

In this case, both knees were considered to be medically unacceptable.  They were both profiled and implicated in the commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.  

The CI’s bilateral knee condition began during basic training in late 1999, when he sustained a twisting injury to the right knee and an injury to the left knee during a PT run.  A bone scan was performed which revealed no increased activity within the hips, knees or ankles.  There was no suspicion for an active bony disease, and there was no surgical indication.  

The 11 July 2003 MEB NARSUM, 9 months prior to separation, noted continued knee pain so that he became unable to satisfactorily perform the physical activities required at the unit.  Physical examination revealed a normal gait without limp and range of motion from 0 degrees extension to 130 degrees flexion (normal 0 to 140).  There was tenderness and obvious crepitus at both retropatellar spaces but no mention of painful motion.  At the 5 January 2004 C&P evaluation, 3 months before separation, the CI reported constant bilateral knee pain especially after running or prolonged standing.  His right knee was worse than his left.  Physical examination showed posture and gait were normal.  There was full range of motion in both knees for the individual due to body type, and the CI winced with pain on both knees prior to putting any pressure on his knee examined.  He expressed pain out of proportion to the examination being done to him.  The examiner noted that the physical examination did not support the severity of pain exhibited by the CI.  He had a full weight bearing, non-antalgic gait and was observed easily ambulating down the main hallway.  ROM was flexion to 120 degrees (normal 140) for the left, and 127 degrees for the right.  Bilateral extension was 0 degrees (normal).  At a 4 January 2005 VA General Medicine visit, 9 months after separation, the CI reported that his physical complaints were resolved, he stated that he had these problems while in Saudi Arabia.  Physical examination showed full ROM of both knees with no effusion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded analogously to 5003 citing “rated for pain.  The VA rated the left and right knee conditions 10% each, coded analogously to 5019 (bursitis), citing painful or limited motion of a major joint or group of minor joints.  There was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There likewise was no 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 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 not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB for each knee.  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 bilateral knee condition.  

Chronic Neck Pain.  The CI’s neck condition began in about 2000 after a motor vehicle crash and then worsened in October 2001 when he sustained an injury to his upper back after a wall locker fell off a vehicle and landed on his head while deployed to Saudi Arabia.  X-ray examination of the cervical spine revealed narrowing of the neuroforamina from C3 thru C7 as well as multi-level vertebrae plana (congenital condition or advanced compression fracture).  There was no surgical indication.  

At the 11 July 2003 MEB NARSUM, 9 months prior to separation, physical examination showed a normal gait.  Evaluation of the cervical spine revealed forward tilt chin to chest, being the distance of four fingerbreadths between the chin and the chest.  On hyperextension there were five-finger breadths distance between the base of the skull and the vertebrae prominens (the C7 vertebral process).  Rotation to the left was 40 degrees with discomfort; to the right was 45 degrees (normal 80) with discomfort localized to the spine and to the trapezius muscle on the left more than on the right.  Lateral tilt was to 20 degrees bilaterally (normal 45) with discomfort again at the trapezius muscle.  At the 5 January 2004 VA C&P evaluation, 3 months before separation, the CI reported constant neck pain.  He reported difficulty turning right and left.  Physical examination showed a normal posture, gait and contour.  The cervical spine ROM measurements showed flexion of 40 degrees (normal 45) and combined ROM of 235 degrees (normal 340) after repetition.  Following repetitive use, there was no decrease in range of motion but there was pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the cervical spine condition coded 5003 (arthritis, degenerative), citing an EPTS [existed prior to service] condition that was not permanently service aggravated.  The VA rated the cervical spine condition 10%, coded 5099-5238 (analogous to spinal stenosis), based on the C&P examination 3 months before separation, citing forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees or, combined range of motion of the cervical spine greater than 70 degrees but not greater than 335 degrees.  

Although not reported as goniometric measurements, the MEB PT examination was similar to the C&P examination.  However, the VA examination proximate to separation was more detailed and reported ROM performed after repetitive motion.  Therefore, the panel placed greater probative value on the VA examination.  Concerning the assertion by the PEB that the CI’s neck condition was EPTS, the panel noted that although it is possible that the abnormal findings on the neck X-rays may have existed prior to service, there was no evidence of neck pain at the MEPS examination or during Basic and Advanced Training.  A presumption of service aggravation may only be overcome by a preponderance of medical evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service.  In this case, there is evidence of an injury during service and symptoms of neck pain greatly increasing neck pain following the injury.  The panel agreed that the presumption of service aggravation was not overcome.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and/or combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the VA examination 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 recommends a disability rating of 10% for the cervical spine condition, coded 5299-5235 (analogous to vertebral fracture).  The panel noted that there were no complaints of neck pain and the spine examination was recorded as normal at enlistment.  The first recorded complaint of neck pain was after the injury which was found to be in the line of duty; therefore, no deduction for an EPTS condition is warranted.  

Contended PEB Conditions:  Bilateral Wrist Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions 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 either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the mechanical low back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 cervical spine stenosis condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5235 IAW VASRD §4.71a.  In the matter of the contended bilateral wrist pain 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 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	
Mechanical Low Back Pain	5299-5237	10%	
Right Knee Chondromalacia	5099-5019	0%	
Left Knee Chondromalacia	5099-5019	0%	
Cervical Spine Stenosis	5299-5235	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160930, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170019439, 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