RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01155
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051212

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Motor Transport Operator, medically separated for “low back pain” and “bilateral knee pain,” rated 0% each, with a combined disability rating of 0%.  

CI CONTENTION:  No specific contention made.  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 - 20051012	VARD - 20060501	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	0%	Lumbar Spine Annular Bulge at L4-L5	5243	20%	20060202	
Bilateral Knee Pain	5099-5003	0%	Right Knee Chondromalacia	5014-5260	10%	20060202	
			Left Knee Pain	5299-5260	NSC	20060202	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in October 2004 after training, marching and jumping from a truck.  The CI reported generalized LBP, without radiating pain or radicular symptoms.  An MRI showed mild degenerative disc disease at L4-5 without neuroforaminal narrowing or central canal stenosis.  There was no surgical indication.  An orthopedic examination on 7 April 2005, 8 months prior to separation, showed flexion to 60 degrees and pain in all planes of motion.  Lower extremity strength, sensation and reflexes were normal and straight leg raise (SLR) testing to elicit radicular symptoms was negative.  The 20 June 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of LBP worsened by exercise.  Physical examination showed full thoracolumbar range of motion (ROM), no tenderness and negative SLR.  

At the 2 February 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported having constant moderate low back pain that radiated into his right buttock.  He also reported having flare-ups a couple times per week causing severe pain.  Physical examination showed a normal gait.  There was tenderness throughout the lumbar spine, but no muscle spasm.  Thoracolumbar ROM was flexion to 85 degrees (normal 90) and combined ROM of 235 degrees (normal 240) with painful motion during flexion beyond 60 degrees and extension beyond 22 degrees.  Right SLR was positive with complaint of stabbing pain in the buttocks.  Lumbar spine X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded 5299-5237 (lumbosacral strain), citing normal ROM without tenderness.  The VA rated the back condition 20%, coded 5243 (intervertebral disc syndrome), based on the C&P examination, citing flexion of the thoracolumbar spine currently greater than 30 degrees but not greater than 60 degrees.  

There was no limitation of thoracolumbar spine motion or presence of painful motion, muscle spasm, guarding or localized tenderness to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine at the MEB NARSUM examination.  The ROM at the VA examination supported a 10% rating, however, the VA examination noted evidence of radicular symptoms not present prior to separation which the panel majority interpreted as post-separation worsening of the CI’s back condition.  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 evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that VASRD formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the 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 adjudicated by the PEB.  The evidence for the right and left knee conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the STR and MEB NARSUM, the CI’s bilateral knee condition began in August 2004 while on a 12 mile road march.  The CI stated that during the march he experienced worsening bilateral knee pain, left greater than right.  Knee X-rays, left knee MRI and bone scan were all normal and surgery was not indicated for either knee.  A primary care examination on 23 August 2004 showed tenderness over the lateral femoral condyles and patellar tendons bilaterally.  There was full ROM of both knees without crepitus.  The diagnosis was retropatellar pain syndrome and patellar tendonitis 

At an orthopedic examination on 7 April 2005 the CI reported left greater than right knee pain with occasional buckling but no locking.  Physical examination showed tenderness to palpation along the patellar borders bilaterally and the left medial joint line.  Bilateral knee ROM was full.  There was lateral tracking of the patella of both knees.  Hand written notes on the same date indicated there was “left knee pain, swelling and joint line pain.”  The permanent profile dated 25 May 2005 listed bilateral knee pain.  There was no commander’s statement in the available records.  The MEB NARSUM determined the CI fell below retention standards due to the bilateral knee condition.  

During the MEB NARSUM examination, 6 months prior to separation, the CI complained of continued bilateral knee pain, made worse with exercise.  Physical examination showed both knees to be non-tender with full ROM.  There was no evidence of instability or meniscal pathology of either knee.  At an orthopedic follow-up on 12 August 2005, 4 months prior to separation, the CI reported the left knee swelled after activity.  Physical examination showed mild left patellar crepitus and tenderness, without effusion.  There was no effusion or tenderness of the right knee.  

At the C&P examination, 2 months after separation, the CI reported constant moderate pain in both knees and daily flare-ups with severe pain that lasted the rest of the day.  Physical examination showed no swelling or effusions.  There was no evidence of instability or meniscal pathology in either knee.  There was moderate crepitus on the right, but no crepitus noted on the left knee.  Right knee flexion was 120 degrees (normal 140) and extension was 0 degrees (normal).  Left knee flexion was 130 degrees (normal 140), with pain beginning at 110 degrees, and extension was 0 degrees (normal).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the USAPDA pain policy.  The VA rated the right knee condition 10%, dual coded 5014-5260 (osteomalacia-limitation of leg flexion), based on the C&P examination, citing chondromalacia with limited motion of a major joint.  The VA determined the left knee condition was not service-connected.  

The panel first considered if the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were permanently profiled and determined to fail retention standards.  However, the CI repeatedly reported left greater than right knee symptoms.  The left knee was noted to swell after activity, but not the right, and an MRI was obtained of the left knee but not the right.  At the MEB NARSUM and orthopedic examinations the right knee was unremarkable.  The panel concluded the left knee condition was reasonably considered unfit but a preponderance of evidence in the record supports the right knee individually would not have caused the CI to be referred into the DES or to be found unfit.  Therefore, the panel considered a rating for the unfitting left knee condition.  

There was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was left knee crepitus and painful motion noted at examinations proximate to separation to support 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 for either knee.  There was no fracture, nonunion or malunion of either femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the unfitting left knee condition, coded 5099-5003 and a not unfitting right knee condition.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 10% but does not elect to submit a minority opinion.  In the matter of the bilateral knee condition, the panel recommends that it be adjudicated for two separate conditions as follows: an unfitting left knee condition with a disability rating of 10%, coded 5099-5003 IAW VASRD 4.71a and a not unfitting right knee condition.  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	
Low Back Pain	5299-5237	0%	
Left Knee Pain	5099-5003	10%	
COMBINED	10%	

AR20180016347, 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 ha ve re vie wed 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 EvaluationBoard 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.