RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01994
BRANCH OF SERVICE:  army	SEPARATION DATE:  20060801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic non-radiating low back pain” and “right iliotibial band syndrome (ITBS),” rated 0% each, for a combined disability rating of 0%.  

CI CONTENTION:  Knee injury caused the back injury and subsequent headaches.  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 - 20060428	VARD - 20061204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Non-Rating Low Back Pain	5299-5237	0%	Lumbar Strain	5237	10%	20060724	
Right ITBS	5399-5313	0%	ITBS, Right Knee	5260	0%	20060724	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an atraumatic onset of back pain in early 2005 which he attributed to an altered gait from the knee pain addressed below.  Imaging (X-ray, MRI) was normal except for some disc desiccation at L5/S1 without nerve impingement.  There were no neurological symptoms or findings, surgery was not indicated, and conservative treatment was not successful.  There were no outpatient STR entries probative to range of motion (ROM) or other ratable features.  A 22 March 2006 orthopedic addendum to the NARSUM documented non-specific low back pain that was aggravated by prolonged sitting or standing.  The physical examination recorded a normal gait, flexion to “hands approximately 1 foot from the floor” (roughly 80 degrees, normal 90), “limited extension and side bending,” and normal neurological findings.  

The 30 March 2006 MEB NARSUM examination, 5 months prior to separation, documented “constant” pain rated 5/10 “that worsens with squatting, bending, running, swimming or lifting more than 30 pounds.”  The physical examination recorded no tenderness and normal neurological findings, without note of abnormal gait or spinal contour.  The NARSUM referenced goniometric ROM measurements by physical therapy conducted 2 weeks earlier (13 March).  These were reported as flexion to 70 degrees with a combined ROM of 205 degrees (normal 240).  

The 24 July 2006 VA Compensation and Pension (C&P) general examination, a week before separation, documented constant pain rated 7/10 interfering with walking, lifting, and running, without any periods of incapacitation.  The physical examination recorded a normal gait, normal spinal contour, tenderness, and normal neurological findings.  Measured ROM was normal in all planes with pain at end-ranges and no degradation with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5299-5237 (analogous to lumbosacral strain), citing “pain-limited motion” that suggested application of AR 635-40 (B-29, e).  The VA rated the condition 10%, coded 5237, citing painful motion from the C&P examination.  

The panel agreed there was satisfactory evidence of painful motion (as acknowledged by the PEB) to support a minimum 10% rating IAW VASRD §4.59.  Furthermore the MEB ROM measurements, corroborated by the orthopedic addendum, satisfied VASRD §4.71a spine criteria for a 10% rating for both flexion and combined ROM.  There was no ROM evidence in support of a higher rating.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour in justification of the next higher 20% rating.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  The panel thus 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 combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported in the MEB ROM examination.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the lumbar condition under code 5237.  

Right ITBS.  The CI suffered an atraumatic onset of right knee pain in early 2004 during basic training that was subsequently diagnosed as ITBS (radiated proximally and laterally).  Imaging (X-ray, MRI) was normal and it was determined that surgery was not likely to be beneficial.  There was ample STR documentation, with no contrary evidence, of grossly normal ROM and the absence of persistent effusion, locking, or instability.  There was no documentation or suggestion of painful motion by any service examiner.  

The orthopedic addendum documented non-specific right lateral knee pain without subjective locking or instability.  The physical examination recorded a normal gait, tenderness, and no instability or impingement.  Measured ROM was flexion to 125 degrees (normal 140, 45 for minimum 10%) with 0 degrees extension (normal), specifying that motion was “nonpainful.”  The NARSUM documented pain “two hours per day” that was rated 3-4/10 and “worsens with kicking, running, walking or marching more than 2 miles.”  The physical examination recorded tenderness, no effusion, no instability or impingement, and “full” ROM with no reference to painful motion.  The VA C&P examination documented intermittent pain throughout the day aggravated by walking, running, and “moderate activity.”  The physical examination recorded a normal gait, no tenderness, no effusion, and no instability or impingement.  Measured ROM was flexion to 140 degrees with 0 degrees extension, specifying the absence of pain or ROM degradation with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 0%, coded 5399-5313 (analogous to the applicable muscle disability code), citing the 0% “slight” criterion of code 5313.  The VA rated the condition 0%, coded 5260 (limitation of flexion), citing the absence of any compensable findings by the C&P examiner.  

There was no evidence of painful motion supporting a 10% rating IAW VASRD §4.59.  There was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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 justify 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).  The panel noted, however, that the PEB’s muscle code 5313 was clinically consistent with the myofascial nature of the diagnosis and anatomically compatible with the iliotibial band.  It was thus well justified IAW VASRD §4.7 (higher of two evaluations).  In addition to the “slight” 0% criterion, code 5313 offers a 10% rating for “moderate” disability; and, although agreeing that no disability greater than moderate could be justified by the evidence, members deliberated whether the moderate 10% criterion was supported.  Ultimately member consensus was that reasonable doubt favored concession of the higher rating under code 5313.  The condition limited prolonged walking and more than “moderate” physical activity (C&P), and logically would have imposed some significant occupational constraints at the time of separation.  The consensus conclusion, therefore, was that the disability in evidence was more fairly characterized as moderate than as slight.  After due deliberation, considering all evidence and conceding VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation is a disability rating of 10% for right ITBS, coded 5399-5313.  

BOARD FINDINGS:  In the matter of the lumbar condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the right iliotibial band syndrome, the panel majority recommends a disability rating of 10%, coded 5399-5313 IAW VASRD §4.73.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  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	
Myofascial Strain, Lumbosacral Spine	5237	10%	
Right Iliotibial Band Syndrome	5399-5313	10%	
COMBINED	20%	

AR20180014723 , 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.