RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-01504
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20071127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Cargo Specialist, medically separated for “lumbosacral strain” rated 10%,   and “left wrist pain and right knee pain” rated 0%, with a combined disability rating of 10%.  

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 - 20071105	VARD - 20090421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Spondylolisthesis	5239-5010	10%	STR	
Left Wrist and Right Knee Pain	5099-5003	0%	Left Wrist Sprain	5299-5215	0%	STR	
			Right Knee Sprain	5299-5261	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Lumbosacral Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in January 2007 with no specific injury or trauma.  Lumbar X-rays and MRI revealed a pars defect and mild spondylolisthesis L5 - S1.  The 31 July 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of back pain.  Physical examination showed lumbar tenderness.  Range of motion (ROM) was flexion to 80 degrees (normal 90) and combined ROM was between 170 degrees and 230 degrees (normal 240).  During the 15 August 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported back pain interfering with sleeping and use of a back brace.  Physical examination revealed “pain low thoracic down L/S (lumbosacral) spine.  Unable to bend forward” and pain with straight leg raise.  The 2 October 2007 MEB physical therapy ROM evaluation, 2 months prior to separation, noted an abnormal posture with the CI observed as having “no difficulties putting on or bending over to grab shoes.  (CI) was then measured and had many limitations.”  Gait and stance were abnormal.  The assessment was lumbago; however, the ROM chart was labeled “cervical.”  The charted ROMs showed flexion of 25 degrees and combined 135 degrees.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing tenderness and limited range of motion limited by pain.  The VA rated the back condition 10%, dual coded 5239-5010 (spondylolisthesis or segmental instability-arthritis due to trauma), based on the STR, citing painful or limited motion.  

In assigning probative value to these somewhat conflicting examinations, the panel noted that the MEB NARSUM measurements were consistent with other proximate (pre-separation) examinations by primary care, earlier physical therapy evaluations, and orthopedic clinics; as well as the diagnostic imaging findings.  The MEB physical therapy ROM was consistent with a flare of back pain, had internal irregularities, and was considered an outlier to the preponderance of the evidence.  

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), and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), and/or tenderness as reported on the MEB NARSUM examination.  Although there were some STR entries documenting muscle spasm, it was not severe enough to result in an abnormal spinal contour, and occasional abnormal gait was often attributed to the CI’s knee condition, thus the next higher 20% back 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 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 lumbosacral strain condition.  

Left Wrist and Right Knee Pain.  The PEB combined the left wrist and right knee conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24f.  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 profile, commander’s statement, MEB NARSUM, and MEB report all separately noted wrist and knee limitations.  Panel members agreed the evidence reasonably justified that the functional limitations of each condition contributed to the CI’s inability to perform his military duties, each was reasonably justified as separately unfitting, and accordingly a separate disability rating is recommended for each.  The ratable evidence for the left wrist and right knee conditions are presented separately, with attendant recommendations regarding separate ratings if indicated.  

Left Wrist Pain.  According to the STR and MEB NARSUM, the right-handed CI’s left wrist condition began in November 2006 following a training week of combatives and pugil stick events.  X-rays were normal with abnormal bone scan showing increased uptake in the ulna.  The MEB NARSUM examination noted complaints of left wrist pain for 6 months.  Physical examination showed no tenderness to the left wrist.  There was “pain at the ulnar portion of his wrist with axial load, for instance, push-ups and any pushing up of his body through his left upper extremity.”  X-ray was normal.  The MEB physical therapy ROM evaluation documented left wrist tenderness with pain-limited motion of flexion to 50 degrees (normal 80) and extension to 55 degrees (normal 70).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist and right knee conditions 0%, analogously coded 5099-5003, citing application of the USAPDA pain policy and ROM limited by pain.  The VA rated the left wrist condition 0%, analogously coded 5299-5215 (wrist, limitation of motion), based on the STR, showing treatment, a normal X-ray, and citing failure to report for a scheduled VA examination.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of wrist motion (5215).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45).  After due deliberation, and considering all the evidence, the panel recommends a separately unfit determination with a disability rating of 10% for the left wrist condition, coded 5299-5215.  

Right Knee.  According to the STR and MEB NARSUM, the CI’s right knee condition began in January 2007 with no specific event or trauma.  At the 22 June 2007 family health clinic, the CI complained of chronic back pain with right knee pain.  Physical examination documented an abnormal gait (limping and bent forward).  There was tenderness to the right shin and knee.  Right knee weakness was observed.  The CI was prescribed a knee brace and cane.    The MEB NARSUM examination noted complaints of right knee pain for the past 6 months.  Physical examination showed mild right knee joint line tenderness and patellar grind.  ROM was extension to flexion approximately 0 to 135 degrees (normal 0 to 140).  X-ray was normal and MRI documented a small joint fluid collection with minimal lateral patellar tilt.  There was no evidence of menisci tear or ligament abnormality.  During the MEB examination the CI reported knee pain with swelling and give way, and wearing a knee brace.  Physical examination revealed mild crepitus and mild discomfort.  The MEB physical therapy ROM evaluation documented right knee tenderness with pain-limited motion of flexion to 115 degrees and extension to 0 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist and right knee conditions 0%, analogously coded 5099-5003, citing application of the USAPDA pain policy and ROM limited by pain.  The VA rated the right knee condition 0%, analogously coded 5299-5261 (leg, limitation of extension), based on the STR, showing treatment, a normal X-ray, MRI showing effusion; and citing failure to report for a scheduled VA examination.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 [flexion] or 5261 [extension]).  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).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45).  After due deliberation, considering all the evidence, the panel recommends a separately unfit determination with a disability rating of 10% for the right knee condition, coded 5299-5260.

BOARD FINDINGS:  In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left wrist and right knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting left wrist condition coded 5299-5215 and rated 10%, and an unfitting right knee condition, coded 5299-5260 and rated 10%, both IAW VASRD §4.71a.  

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	
Lumbosacral Strain	5237	10%	
Left Wrist Pain	5299-5215	10%	
Right Knee Pain	5299-5260	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007941, 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