RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01630
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20071214

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

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 - 20071026	VARD - 20080429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	0%	L4-5 Disc Narrowing	5242	10%	20080414	
Bilateral Knee Pain	5099-5003	0%	Bilateral Chondromalacia and Patellar Tendinitis	5009-5003	10%	20080307	
Chronic Posttraumatic Stress Disorder (PTSD)	Not Unfitting	PTSD	9411	30%	20080305	
Snapping Hip Syndrome	Not Unfitting	Bilateral Hip Pain	5099-5010	Not Service Connected	20080311	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was in a serious motor vehicle accident at age 16 with loss of consciousness and a back injury among other issues.  He was cleared for accession after a 5 year post-accident observation period.  The first record in evidence for a musculo-skeletal issue while on active duty was a primary care re-evaluation on 22 January 2007 for right knee and right hip pain, both aggravated by activity.  He subsequently reported that this pain had begun a year earlier while deployed.  On 7 March 2007 he was noted to have full and pain free lumbar range of motion (ROM).  In orthopedics on 18 April 2007, the CI was noted to have normal motor function and reflexes.  Provocative testing for nerve root irritation was negative to 90 degrees.  The ROM was full in all planes, but flexion was painful.  Sensation of the entire left leg was reduced compared to the right.  It was noted that a CT scan showed bilateral spondylolysis (a defect in the part of the vertebra which connects it to another vertebral body) at L4.  This was thought to be a congenital anomaly.  X-rays that day showed evidence of degenerative disc disease (DDD) at L4-5 and L5-S1 as well as degenerative changes of the left sacroiliac joint (the right side had been injured in the car accident addressed above).  On 26 April 2007 the CI was again noted to have full and pain-free lumbar motion.  An MRI of the lumbar spine the same day confirmed the spondylolysis and noted that the vertebral bodies were correctly aligned (no slippage due to the spondylolysis).  In primary care on 29 June 2007, the CI was noted to have tenderness of the thoracolumbar spine, but a normal neurological examination and gait.  An MRI of the thoracic spine on 6 July 2007 showed a small herniation at T2-3 with soft tissue edema at T8.  

The CI was seen for a second opinion in orthopedics on 3 August 2007.  He reported pain with walking or carrying weight.  Bilateral leg pain was noted which was in a non-dermatomal pattern (unrelated to a back problem).  He was noted to have normal flexion at 90 degrees and pain with extension of 15 degrees.  Motor function was normal.  In physical therapy on 21 August 2007, 4 months prior to separation, flexion was measured at 60 degrees with 175 degrees of combined ROM.  One (of 5) signs of non-organic pain was present.  The next day in primary care, he was noted to have no abnormalities of the thoracolumbar or lumbosacral spine.  The neurological examination and gait were normal.  One week later, decreased ROM of the lumbosacral spine was noted (without further detail), but the examination was otherwise unchanged.  This examination was duplicated on 19 September 2007.  

The 27 September 2007 MEB NARSUM examination, 3 months prior to separation, recorded complaints of persistent pain.  He was working a 4 hour day and did light physical exercise.  He wore bilateral knee braces and used a cane when his pain (not specified) was severe.  The ROM measurements from physical therapy were cited.  No comment was made regarding the gait or the presence of tenderness or spasm.  

There were multiple VA Compensation and Pension (C&P) examinations in evidence in the 12 months following separation.  At the joint evaluation on 7 March 2008, 3 months after separation, the examiner reported “numerous complaints with strongly voiced symptoms that appear to not be balanced with detectable physical abnormalities.”  On entrance, the CI was noted to have a “remarkably bizarre gait…” and leaned “heavily on his cane.”  On examination, he disrobed in a slow fashion and changed position with use of his arms and signs of discomfort.  Back tenderness was inconsistently present in multiple sites, but mostly the right paravertebral aspect of the thoracic spine.  Flexion was 80 degrees.  Extension was 15 degrees as were left and right lateral bending.  The CI stated that he was incapable of rotation (the panel noted that rotation had been 20 degrees bilaterally at the physical therapy examination).  Four days later in the general examination, he was noted to have an antalgic gait (abnormal due to pain) and to use a cane.  The neurological examination was normal.  One month later in neurosurgery, he was found to use a cane and brace (it is not clear if this was for the back or the knees).  Tenderness and spasm were present and the abnormal gait attributed to the latter.  The neurological examination was normal other than a non-dermatomal loss of sensation of the left upper extremity.  The ROM testing showed flexion of 50 degrees and a combined ROM of 125 degrees (with rotation 15 degrees bilaterally).  Painful motion was present.  

A neurology C&P was performed on 22 September 2008, 9 months after separation, for a possible traumatic brain injury.  The pre-service injury was noted.  On examination, sensation, strength, and reflexes were normal.  The tone was normal as was the gait.  One month later, the CI was again seen in neurology and requested a transfer of care out of the VA system.  On examination, he used a cane and walked with a limp.  Quadriceps and hamstring strength was reduced bilaterally and symmetrically, but the motor function was otherwise normal.  Sensation and reflexes were intact.  It was noted that electrodiagnostic testing had shown a chronic right S1 radiculopathy.  A review of the record did not show a history of incapacitation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain), IAW AR 635-40.  The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examinations 3 and 4 months after separation, citing 80 degrees of flexion.  The panel considered the evidence.  There was one record of an abnormal gait due to spasm, but others showed an abnormal gait due to the knees or a normal gait.  Flexion was normal or near normal on 3 examinations and 50 and 60 degrees on 2 examinations.  The neurological examination was normal on most examinations.  The panel observed inconsistencies between the examinations and annotations that the symptoms were not supported by the physical evidence.  The panel determined that the preponderance of evidence supported the 10% rating adjudicated by the VA.  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 pain condition, coded 5237.  

Bilateral Knee Pain.  The PEB combined the left and right 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 of the PEB.  The evidence for the right and left knee pain conditions are presented together, but with attendant individual recommendations regarding separate unfitness, and separate rating if indicated. 

According to the STR and the MEB NARSUM, the CI was reevaluated for right knee pain in primary care on 22 January 2007 as noted above.  The examination of the right hip was normal and the right knee showed normal ROM.  The knee was without signs of meniscal irritation, swelling, instability, or tenderness.  Motion was pain free.  In primary care on 7 March 2007, both knees were stable and motion was pain free.  In orthopedics on 18 April 2007, both knees had full ROM.  Crepitus was noted, but pain was not documented.  The knees were stable.  Signs of meniscal irritation were not recorded.  X-rays were normal.  On 26 April 2007, the CI was again noted to have stable knees and motion was pain free.  In orthopedics on 9 May 2007, both knees had full ROM.  Crepitus was noted, but pain was not documented.  The knees were stable.  Signs of meniscal irritation were absent.  A medial pop was heard on the right when the CI squatted.  An MRI of the right knee on 25 May 2007 showed a questionable medial meniscus tear (MMT).  On 9 June 2007 in sports medicine, the CI was noted to have bilateral tenderness and signs of meniscal irritation.  No fluid was present.  The ROM was full; painful motion was not documented.  Patellofemoral pain was present bilaterally as was patellar (kneecap) subluxation.  Signs of meniscal irritation were present bilaterally.  An MRI of the left knee on 22 June 2007 also showed a questionable MMT.  

On 18 July 2007, the CI was noted to have a positive patellar grind (consistent with degenerative changes of the patella), but the knee was stable and signs of meniscal irritation were absent.  One week later in orthopedics, the right knee MRI was reviewed and thought not to show an MMT.  On examination, crepitus was present.  The knee was stable with full flexion (140 degrees).  Extension was to +5 degrees (it is not clear if this meant 5 degrees short of full extension of 0 degrees or 5 degrees past 0).  The CI was thought to have degeneration of the patellar cartilage and also inflammation of the patellar tendon.  He was advised to continue normal activities, but to avoid stairs and carrying heavy loads especially with deep knee bends or squatting.  No comment was made regarding the use of a cane or a brace.  Two weeks later the CI was seen in primary care and using a cane, which he reported was at the advice of the knee specialist.  

In physical therapy on 21 August 2007, flexion was measured at 140 degrees and extension at 0 degrees, both normal.  On 29 August 2007 in family practice, the CI was noted to be wearing bilateral knee braces, but to have a normal gait.  On the DD Form 2808, the CI was noted to be wearing bilateral knee braces, but to have ROM of 0-135 degrees when distracted.  The 27 September 2007 MEB NARSUM examination, just over 2 months prior to separation, noted complaints of ongoing knee pain.  The CI was working 4 hours a day and wore bilateral knee braces with exercise.  He used a cane when the pain was severe.  On physical examination, the ROM was normal.  Painful motion was not recorded.  No comment was made on either stability or the presence of signs of meniscal irritation.  

At the C&P joint examination on 7 March 2008, 3 months after separation, the CI reported “numerous complaints with strongly voiced symptoms that appear to not be balanced with detectable physical abnormalities.”  On entrance, the CI was noted to have a “remarkably bizarre gait…” and leaned “heavily on his cane.”  On examination, the ROM was full, but painful motion was not documented.  Crepitation, previously noted, was absent.  The knee was stable.  Signs of meniscal irritation were not recorded.  Four days later in the general examination, he was noted to have an antalgic gait (abnormal due to pain) and to use a cane.  The neurological examination was normal.  One month later in neurosurgery, he was found to use a cane and brace (it is not clear if this was for the back or the knees).  Tenderness and spasm were present and the abnormal gait attributed to the latter.  The neurological examination was normal other than a non-dermatomal loss of sensation of the left upper extremity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated the bilateral knee condition 10%, also coded 5099-5003, based on the STR and multiple VA C&P examinations.  The panel first considered if the knees were separately unfitting.  The bilateral knee condition was profiled and determined to be medically unacceptable by the MEB.  The commander did not specify which conditions contributed to duty impairment.  The evidence did not overcome the presumptive determination that each knee was individually unfitting at separation.  The panel then considered the evidence.  The ROM was normal on the majority of examinations and was not compensable on any examination under a code specific for the knees.  Painful motion was generally not recorded although the CI frequently had a limp and used knee braces bilaterally.  Crepitus was recorded bilaterally on multiple examinations, but not on all examinations.  The MRIs were not thought to show MMTs of either knee although degeneration was present in both medial menisci.  This supports a 10% code for the bilateral knee condition using the analogous code for degenerative arthritis (5099-5003).  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 bilateral knee condition, coded 5099-5003.  

Contended PEB Conditions:  Chronic PTSD, Snapping Hip Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither condition was implicated in the commander’s statement.  Both were judged to meet retention standards.  The PTSD condition was profiled S2, but this is acceptable for many military occupations.  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, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the bilateral knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended chronic PTSD and snapping hip conditions, the panel recommends no change from the PEB determinations 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	10%	
Bilateral Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005410, 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