RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01262
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “chronic back and bilateral knee pain” with a disability rating of 0%.  

CI CONTENTION:  “When I received the rating which rendered me unfit, I was told that my condition would improve, it has not.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040614	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back and Bilateral Knee Pain	5099-5003	0%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA 	

ANALYSIS SUMMARY:  

Chronic Back and Bilateral Knee Pain.  The PEB combined the back and bilateral knee conditions under a single disability rating, coded analogously to 5003 and rated 0%, with application of the U.S. Army Physical Disability Agency (USAPDA) pain policy.  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 of the PEB.  The evidence for the back and bilateral knee conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began without injury or trauma during intense physical training in February 2003.  On 15 August 2003, X-rays were normal and she had full back range of motion (ROM).  A physical therapy (PT) evaluation on 8 September 2003 showed lumbar spine ROM within normal limits, but tenderness at L4-5 and L5-S1.  The examiner noted the CI had a chronic overuse syndrome and mechanical low back pain and opined that her body type was not conducive to the strenuous labor she was tasked to do with her military specialty.  

During the 12 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, physical examination revealed full back ROM with pain.  A bone scan on 18 November 2003 demonstrated mild focal increased bone activity at the right fourth costosternal (rib-breast plate) junction with the differential diagnosis including occult trauma and mild degenerative joint disease.  Views of the thoracic spine, lumbar spine, pelvis, and knees were normal. 

The 17 March 2004 MEB NARSUM examination, 3 months before separation, showed normal gait and station, and full spinal ROM in all planes, with mild discomfort at the extremes.  The examiner diagnosed “low back pain secondary to chronic overuse syndrome.”  On March 2004, PT ROM measurements showed flexion of 65 degrees (normal 90) and combined ROM of 215 degrees (normal 240).  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  As mentioned above, the PEB rated the bundled the back and knee conditions 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the USAPDA pain policy.  Members concluded that the preponderance of evidence showed the back condition, standing alone, was separately unfitting for continued military service.  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 PT examination, which was closest 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.  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 and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back condition, coded 5237.  

Chronic Bilateral Knee Pain.  According to the STR and MEB NARSUM, the CI’s bilateral knee pain began in February 2003 in the absence of trauma.  Examination of the knees on 15 August 2003 revealed full ROM and no swelling or evidence of a meniscal tear, laxity or joint line tenderness.  Knee X-rays showed normal appearing joint spaces without degenerative, inflammatory or post-traumatic changes.  At a PT evaluation on 8 September 2003, the CI indicated the pain was located “inside” the knees and in the popliteal fossae (behind the knees).  Bilateral knee ROM was normal with no swelling or tenderness.  Laxity, meniscal tear, and patellar grind testing was negative.  The examiner’s assessment was chronic overuse with bilateral patellofemoral pain syndrome.  
A bone scan performed on 18 November 2003 was normal, and orthopedic evaluation on 30 December 2003 showed excellent stability of the knees with slight laxity of the right patella compared to the left; however, the patella could not be subluxed or dislocated.  Apley grinding and compression tests were mildly positive, and the examiner felt the knee findings were consistent with an overuse syndrome; neither surgery nor an MRI were indicated.  At a PT visit on 24 March 2004, the CI reported (on a knee assessment questionnaire) a slight/periodic limp, constant pain, swelling after strenuous activities and a slight problem with stairs and squatting, but no locking and rare instability during athletic activities or physical exertion.  Bilateral knee ROM was 0-135 degrees (normal 0-140) during the first repetitive tests and 0-140 degrees in the next series.  There was no swelling or ecchymoses (black and blue marks). 

During the MEB examination, the CI reported consistent knee pain since advanced individual training.  Physical examination revealed decreased knee ROM with weight bearing.  The MEB NARSUM examination noted CI complaints of bilateral knee pain, and the provider documented symmetrical lower extremity findings with full ROM of each knee.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled back and knee conditions 0%, analogously coded 5099-5003.  Members concluded that the preponderance of evidence showed that the CI’s left and right knee conditions were separately unfitting, based on the issuance of temporary profiles and the inability to fully train and perform the duties of her military specialty.  The panel then discussed applicable ratings for each knee and noted there was no limitation of flexion or extension (5260, 5261) or evidence of objective painful motion with functional loss (based on §4.59, §4.40 and §4.45) to support a 10% rating.  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 for either knee; and 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 degenerative arthritis (5003) was present clinically or supported by X-ray evidence of involvement of two or more major joints or two or more minor joints, nor was there any evidence of occasional incapacitating exacerbations to warrant a rating of 10% or more with use of that code.  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 for either knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the bilateral knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic back pain condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the chronic bilateral knee pain condition, the panel recommends a disability rating of 0%, coded 5099-5003 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5237	10%	
Chronic Bilateral Knee Pain	5099-5003	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161003, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180009782, 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