RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01825
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090701

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Combat Engineer, medically separated for “low back pain” and “left knee pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  PTSD should have been rated.  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 - 20090407	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	No VA Examination Proximate to Separation in Evidence	
Left Knee Pain	5099-5003	10%		
Anxiety Disorder	Not Unfitting  		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent left lateral meniscus repair on 14 February 2008.  The 1 August 2008 physical therapy range of motion (ROM) study showed full ROM and a normal gait.  Orthopedics also noted full ROM on 29 August 2009.  A post-separation MRI showed degeneration of the posterior horn at the medial meniscus.  The CI was offered diagnostic arthroscopy, but declined as it was not thought that he would be able to return to full duty.  

During the December 2008 MEB examination (recorded on DD Forms 2807-1 and 2808) 7 months prior to separation, the CI reported popping and swelling.  The physical examination showed tenderness at the lateral meniscus area, but no edema or redness and full ROM.  The 16 January 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of persistent left knee pain.  The physical examination showed full ROM, normal gait and normal motor function.  Provocative testing to elicit meniscal pathology was negative.  The knee was stable without joint line tenderness.  Formal ROM testing in physical therapy on 20 February 2009 showed left knee flexion to 130 degrees (normal 140), limited by pain, with normal extension of 0 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 left knee condition 10%, coded 5099-5003 (analogous to arthritis), citing painful motion.  The panel observed the ROM was either normal or near normal on all examinations after recovery from surgery.  A rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) was not supported.  The lateral meniscus was repaired (5259), but neither locking nor an effusion was present to support a rating under the code 5258.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  There was no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 left knee condition.  

Low Back Pain.  According to the STR and MEB narrative summary (NARSUM), the CI’s low back pain (LBP) started in December 2008 after “head banging” while playing in his rock band.  During the 15 December 2008 MEB examination (recorded on DD Forms 2807-1 and 2808) 7 months prior to separation, the CI reported that he “tore his back up” while deployed.  The physical examination showed tenderness.  Provocative testing for nerve root irritation was negative.  Muscle strength and reflexes were normal.  Pain was noted on flexion.  At the physical therapy examination on 8 January 2009, lumbosacral ROM was full, but there was pain at the end of extension.  The gait and motor examinations were normal as were X-rays.  In physical therapy on 12 January 2009, the lumbosacral ROM was full, but painful.  The gait was non-antalgic and there were no spasms.  

The MEB NARSUM examination on 16 January 2009, showed no significant spasm.  Provocative testing for nerve root irritation was borderline on the right.  The neurological examination was non-pathologic.  Thoracolumbar ROM showed flexion of 65 degrees (normal 90) and combined ROM of 200 degrees (normal 240).  Toe and heel walk and proprioception were intact.  On 20 January 2009, the CI reported in physical therapy that treatment was beneficial.  The next day in case management, he noted that he had been able to go snow-boarding over the weekend, but that he “threw his back out” the prior evening while reaching for cigarettes.  On 5 February 2009, the CI was again seen in physical therapy and noted to have 80 degrees of lumbosacral flexion and 20 degrees of extension (normal 30).  The gait was non-antalgic and spasms were absent.  

At the pain clinic examination on 13 February 2009, lumbar flexion was 60 degrees, limited by hamstring tightness, and extension was 10 degrees without radicular pain.  Formal ROM testing in physical therapy on 20 February 2009 showed flexion of 55 degrees and combined ROM of 180 degrees, limited by pain.  An MRI on 9 March 2009 showed multi-level degenerative disc disease (DDD) with possible impingement of the left L5 nerve root.  In primary care on 13 March 2009, the CI was noted to have poor flexion due to pain, but could sit comfortably on the examination table and move smoothly from the floor to the table.  Spasm was present in the left paraspinal region.  The gait and neurological examination were normal.  A discogram performed on 26 March 2009 noted that the CI reported pain during a sham injection and that the reported LBP was incongruent with his actions (playing in a rock band).  However, a follow-up CT scan confirmed the presence of multi-level DDD.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing tenderness and painful ROM.  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 on the preponderance of examinations.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Contended PEB Condition:  Anxiety Disorder (contended as PTSD).  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled and did not fail retention standards.  The commander noted that the CI would be an outstanding Soldier if he could get his knee repaired.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS: In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder, the panel recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004894, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
Enclosure