RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01834
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040914

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Military Police, medically separated for “posttraumatic arthritis left knee,” “cervical spine strain” and “low thoracolumbar degenerative changes,” rated 10%, 0% and 0%, respectively, with a combined disability rating of 10%. 

CI CONTENTION:  “Please 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 FPEB - 20040608	VARD - 20050921	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Arthritis Left Knee	5010	10%	S/P anterior Cruciate Ligament Repair, Left Knee	5299-5260	10%	20050504	
Cervical Spine Sprain	5237	0%	Cervical Spine Injury	5237-5242	0%	20050504	
Low Thoracolumbar Degenerative Changes	5299-5237	0%	Low Thoracolumbar Degenerative Disc Disease	5242-5237	10%	20050504	
Right Shoulder Impingement	Not Unfitting	Right Shoulder Impingement Syndrome	5099-5020	10%	20050504	
Mild Right Carpal Tunnel Syndrome	Not Unfitting	Bilateral Carpal Tunnel Release, Right Wrist…	8599-8515	NSC	20050504	
Hypertension	Not Unfitting	Hypertension	7101	0%	20050504	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Posttraumatic Arthritis Left Knee.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in 2001 when he fell against a wall playing basketball.  Radiographic imaging revealed an anterior cruciate ligament (ACL) tear as well as meniscal damage.  In November 2002 the CI underwent surgical repair of the ACL followed by physical therapy (PT).  In June 2003, the CI underwent an arthroscopy for meniscal debridement of the same knee.  

At the 28 January 2004 MEB NARSUM examination, 8 months prior to separation, his physical examination (PE) revealed left knee tenderness without an effusion.  Range of motion (ROM) of the knee was painful and measured at 125 degrees of flexion (normal 140).  Knee extension was not documented.  Ligament stability tests were negative and lower extremity strength was normal.  

At the 4 May 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported an ability to walk 1 to 3 hours four times per week with no assistive devices.  The record noted that any aspect of knee pain did not interfere with him attending school.  His PE revealed a normal gait.  Left knee ROM revealed normal extension and flexion to 120 degrees.  ROM was not affected by repetitive motion.  Instability testing was negative and no effusion was present.    

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition at 10%, coded 5010 (arthritis, due to trauma), citing ACL repair and meniscal debridement with stable ligaments.  The VA rated the left knee condition at 10%, analogously coded as 5260 (leg, limitation of flexion), based upon the C&P examination, citing left leg flexion limited to 45 degrees.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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 based upon the MEB examination.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes. There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore 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.  

Cervical Spine Sprain.  According to STR and the MEB NARSUM, the CI’s neck condition began in October 2001 associated with the same basketball-related injury as previously described above.  X-rays revealed a protruding disc at the cervical-thoracic junction.  The 28 January 2004 MEB NARSUM examination was silent in regards to the cervical spine.  The 27 May 2004 neurosurgery examination showed normal sensation, reflexes and motor strength.  Decreased cervical extension was noted without numerical identification.  Throughout the calendar year of 2004, the CI was seen and treated by a chiropractor, but the provider’s documentation of spinal ROM was documented in a confusing and non-traditional medical manner and therefore, held little probative value for rating.  

At the 4 May 2005 C&P evaluation the CI reported 3-5/10 neck pain, aggravated by prolonged standing or sitting.  The PE noted “mild tenderness to percussion over the cervical area” without spasms.  Cervical flexion was normal and the examiner noted the CI as having “discomfort” during neck movement.  Neurologic examination, deep tendon reflexes and sensation examinations were all normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition at 0%, coded 5237 (cervical strain), citing full ROM.  The VA also rated the neck condition at 0%, dual coded 5237-5242 (cervical strain-degenerative arthritis of the spine), based upon the C&P examination, citing non-compensable evaluation for forward flexion of the cervical spine greater than 40 degrees.  There was no limitation of cervical spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine and the examinations prior to separation did not note the presence of painful motion, muscle spasm, guarding or localized vertebral tenderness.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  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’s adjudication for the neck condition. 

Thoracolumbar Degenerative Changes.  According to STR and the MEB NARSUM, the CI’s back condition began in September 2002 pursuant to a motor vehicle accident.  Radiographic imaging revealed probable compression deformities, multi-level degenerative changes with neuro-foraminal narrowing at T12-L1 and wedge deformity at T12.   

At the 28 January 2004 MEB NARSUM examination his PE revealed minimal tenderness.  Spinal flexion, extension, and side bending were normal and the CI was able to touch his toes.  His gait was normal.  The CI had frequent chiropractic encounters with regards to the thoracolumbar spine which indicated persistent manipulation techniques were performed to the upper thoracic spine as well as the mid and lower lumbar spine.  Such ROM notations were medically uninterpretable and held little probative value for disability rating.  

At the 4 May 2005 C&P evaluation the CI reported low back pain without radicular symptoms.  His PE showed no evidence of muscle spasm or tenderness over the lower lumbar area.  Thoracolumbar ROM revealed forward flexion to 80 degrees (normal 90), extension to 25 degrees (normal 30), and normal bilateral flexion and rotation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 0%, coded analogously as 5237 (lumbosacral strain) citing full ROM.  The VA rated the back condition at 10%, dual coded 5242-5237 (degenerative arthritis of the spine-lumbosacral strain), based upon the C&P examination citing forward flexion of the thoracolumbar spine greater than 60 degrees.  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 reported on the VA examination.  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.  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 condition.  

Contended PEB Conditions:  Right Carpal Tunnel Syndrome and Hypertension.  The panel’s main charge is to assess the fairness of the PEB’s determination that the above contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at or near separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB’s fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

Right Shoulder Impingement.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended right shoulder condition was not unfitting.  In October 2001, the CI injured his right shoulder after falling into a wall.  At the 8-month pre-separation NARSUM examination, his PE revealed the right shoulder had full ROM without atrophy or gross abnormality.  Upper extremity strength was normal.  The right shoulder was not implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the right shoulder condition significantly interfered with satisfactory duty performance at or near separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB’s  fitness determination for the right shoulder condition and so no additional disability rating was recommended.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change from the PEB’s adjudication.  In the matter of the neck condition and IAW VASRD §4.71a, the panel recommends no change from the PEB’s adjudication.  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the contended carpal tunnel, hypertension and right shoulder conditions, the panel recommends no change in the PEB’s adjudication as not unfitting conditions.  There were 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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Posttraumatic Arthritis Left Knee 	5010	  10%	
Cervical Spine Sprain 	5237	 0%	
Low Thoracolumbar Degenerative Change	5299-5237	10	
COMBINED	   20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170314, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180005421, 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