RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00654
BRANCH OF SERVICE:  army	SEPARATION DATE:  20071022

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “bilateral patellofemoral arthritis” and “chronic back pain,” rated 10% each, with a combined disability rating of 20%.

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 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 - 20070820	VARD - 20081124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Arthritis	5003	10%	Residuals, Right Knee Patellofemoral Syndrome	5014-5260	10%	20080908	
			Residuals, Left Knee Patellofemoral Syndrome	5014-5260	10%		
Chronic Back Pain	5299-5242	10%	Lumbar Strain	5237	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Bilateral Patellofemoral Arthritis.  The PEB rated the bilateral knee condition 10% under a single disability rating, coded 5003 (arthritis, degenerative).  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.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee condition began insidiously in approximately 2002.  X-rays dated 18 December 2006 demonstrated indistinct anterior soft tissues bilaterally suspicious for patellar tendinopathy, worse on the right.  An MRI on 12 May 2007 of the right knee showed intrasubstance degeneration of the medial meniscus with irregularity at the inferior aspect of the posterior horn that may have represented an underlying tear, while intrasubstance degeneration of the lateral meniscus showed no evidence of a tear.  Cruciate ligaments were intact and there was chondromalacia of the patella with subchondral cystic changes.  An MRI of the left knee also on 12 May 2007 showed intrasubstance degeneration of the medial and lateral menisci with some irregularity of the anterior-superior surface of the medial meniscus with subchondral changes.

At a physical therapy evaluation on 4 June 2007, 5 months before separation, right knee range of motion (ROM) was 0 to 134 degrees (normal extension 0 to normal flexion 140), while the left knee ROM was 0 to 133 degrees.  Painful motion and swelling were not addressed for either knee.  Two primary care evaluations in June 2007, 5 and 4 months before separation, revealed bilateral knee crepitus, no knee swelling or tenderness, negative meniscus testing, and “full” ROM.  Painful motion was not addressed.  The 7 August 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral knee pain and stiffness along with bilateral popping.  Physical examination showed no bilateral effusion, but patellofemoral compression pain and anterior medial and lateral knee joint line tenderness were present.  There was right knee patella crepitus; the left knee was not addressed.  Bilateral knee stability testing was negative.  Right knee ROM was 0 to 121 degrees, and left knee ROM was 0 to 120 degrees.  Painful motion and meniscus testing were not addressed.

At the 8 September 2008 VA Compensation and Pension (C&P) joints examination, 11 months after separation, the CI reported daily bilateral knee stiffness and pain.  Physical examination revealed the gait within normal limits.  There was bilateral knee tenderness but no instability.  Bilateral knee ROM was 0-130 degrees with no complaint of pain.  Knee swelling, crepitus, and meniscus testing were not addressed. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5003 (arthritis, degenerative), citing no ratable limitation of motion and X-ray evidence of two major joints.  The VA rated each knee condition 10%, coded 5014-5260 (osteomalacia-leg, limitation of flexion), based on the C&P joints examination, citing bilateral knee tenderness and limitation of 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.  The bilateral knee condition was permanently L3 profiled and implicated by the commander’s statement as chronic knee pain that prevented the CI from performing his military specialty.  The objective clinical and radiologic evidence proximate to separation remained equivocal to both knees without significant indication of either side being more impaired than the other.  The panel concluded there was not a preponderance of evidence in the service records to overcome the panel’s presumption that the bundled right and left knee conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right and left knee conditions.

The panel agreed there was no limitation of flexion or extension proximate to separation that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was sufficient evidence of painful motion with functional loss supporting a 10% rating for each knee (based on §4.59, §4.40 and §4.45), as recorded by the physical therapy, primary care, and VA examinations, which manifested as knee tenderness, crepitus, swelling, and positive patellofemoral compression testing.  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), and no grounds for additional rating based on the presence of instability.  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for each knee condition coded 5099-5003 IAW 4.71a.

Chronic Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition began in 1998 when he went for a run then did pullups and felt something pull in his back.  Lumbar spine X-rays in March 2006 demonstrated a left L5-S1 paracentral disc protrusion contacting and displacing the left S1 root.  Subsequent lumbar spine X-rays in April 2007 were normal.  MRI performed on 5 June 2007 showed mild L5-S1 disc dehydration (reduced flexibility and height) and L3-L5 facet joint hypertrophic changes (degeneration and enlargement).  X-rays on 7 August 2007 showed posterior L5 disc spacing narrowing.

A physical therapy evaluation on 4 June 2007, 5 months before separation, revealed thoracolumbar ROM of flexion to 45 degrees (normal 90) and combined ROM was 135 degrees (normal 240); painful motion was present.  At a primary care clinic visit on 5 June 2007 the examiner noted an EMG done off post was a “normal study” with no electrical evidence of neuropathy or radiculopathy involving the left leg.  At an orthopedic clinic visit on 14 June 2007 the examiner opined the CI had axial low back pain, although his symptoms seemed to be more discogenic and facet joint arthritis.  The physical therapist felt the CI was not a surgical candidate and could be managed by his primary care physician.  

The 07 August 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of low back pain which did not migrate into his buttocks or legs.  Physical examination showed an antalgic gait secondary to the knee condition, although the CI was able to toe-heel walk.  There was spinal tenderness.  Straight leg testing for radiculopathy was positive; however, there was no lower extremity weakness, but some bilateral plantar foot area numbness was present.  Flexion was to 85 degrees and combined ROM was 200 degrees.  Painful motion, posture, and muscle spasm were not addressed.

At the 8 September 2008 C&P general examination, 11 months after separation, the CI reported daily low back pain without flare-ups or radiating pain.  There were no incapacitating episodes in the prior 12 months.  Physical examination revealed a normal gait with no spinal tenderness or muscle spasm.  Posture and straight leg raising testing were not addressed.  ROM was flexion to 85 degrees and combined ROM was 220 degrees; painful motion was present. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing painful motion and spinal tenderness.  The VA rated the back condition 10%, coded 5237 (lumbosacral strain), based on the C&P general examination, citing limitation of flexion.

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 recorded by the MEB NARSUM and VA examinations most 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.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  Although the STR indicated a history of radiating back pain, this pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  Therefore, the panel concluded that an additional disability 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 there was insufficient cause to recommend a change in the PEB adjudication for the back condition.

BOARD FINDINGS:  In the matter of the bilateral patellofemoral arthritis condition, the panel recommends a disability rating of 10% for the right knee condition and a disability rating of 10% for the left knee condition, both coded 5099-5003 IAW VASRD §4.71a.  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Patellofemoral Arthritis	5099-5003	10%	
Left Patellofemoral Arthritis	5099-5003	10%	
Chronic Back Pain	5299-5242	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180006535, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure