RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02689
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060324

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Unit Supply Specialist, medically separated for “bilateral retropatellar pain syndrome,” “chronic neck pain,” and “chronic low back pain,” rated 10%, 0% and 0%, respectively, 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 - 20060225	VARD – 20061027	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Retropatellar Pain Syndrome	5099-5003	10%	Retropatellar Pain Syndrome, Right	5299-5261	10%	20060715	
			Retropatellar Pain Syndrome, Left	5299-5261	10%		
Chronic Neck Pain 	5299-5241	0%	Cervical Degenerative Disc Disease	5243	0%		
Chronic Low Back Pain	5237	0%	Lumbar Disc Disease	5243	0%		
Status Post [S/P] Acromioplasty, Right Shoulder	Not Unfitting	S/P Acromioclavicular Resection; Acromioplasty, Right Shoulder Degenerative Joint Disease	5201	0%		
S/P Right Carpal Tunnel Release	Not Unfitting	Carpal Tunnel Syndrome, Right Hand	5299-5220	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Retropatellar Pain Syndrome.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10%.  The 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 also 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 the PEB’s approach of 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 conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s knee condition began in 2003 without any specific history of trauma or injury.  Diagnostic imaging documented patellar chondromalacia of both knees.  During the 10 June 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported pain and locking in both knees requiring the use a cane for walking.  Physical examination showed full bilateral knee range of motion (ROM) with no effusions, but there was pain with patellar compression, flexion and extension.  The 14 September 2005 MEB NARSUM examination, 6 months before separation, noted complaints of bilateral knee pain, left worse than right, and that the left knee tended to catch after sitting for long periods.  Physical examination showed no effusion or instability, but there was retropatellar pain with full flexion and extension as well as pain with compression of the patellae.  

At the 15 July 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported worsening bilateral knee pain.  Physical examination showed a normal gait and no tenderness or laxity.  Bilateral knee ROM testing, following repetitive movement, revealed flexion of 90 degrees (normal 140) and extension of 0 degrees (normal) with pain throughout.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (degenerative arthritis), as noted above, citing pain with flexion and extension.  The VA rated the right knee and left knee conditions 10% each, analogously coded 5299-5261 (limitation of leg extension), based on the VA C&P examination, citing painful motion of each knee.  

The commander’s statement, profiles, NARSUM, and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude impairment from either knee would not have unacceptably interfered with the military duty performance, members agreed each knee was reasonably justified as separately unfitting.  

The panel noted the objective findings and associated disability for each knee were nearly identical and that respective ratings should therefore be the same.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion (5260) or extension (5261).  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), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was also 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).  However, the panel concluded that there was sufficient evidence of painful motion and functional loss after repetitive use to support a 10% rating for each knee IAW §4.59 and §4.40.  After due deliberation, and considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, both coded 5099-5003.  

Chronic Neck Pain.  According to the STR and MEB NARSUM, the CI underwent an anterior C5-6 cervical discectomy with prosthetic disc insertion in August 2005 for degenerative disc disease with right C6 radiculopathy.  The MEB NARSUM examination, 1 month after surgery, noted complaints of neck pain with radiation to the left arm.  Physical examination showed a normally healing neck scar, and the ROM study showed left and right rotation “almost to full” and “good” extension and flexion.  There were no spasms.  The 14 January 2006 physical therapy (PT) MEB ROM examination, 2 months prior to separation, revealed flexion to 35 degrees (normal 45) and combined ROM of 115 degrees (normal 340).  

At the C&P examination, the CI reported improving mild pinching pain in his neck.  Physical examination revealed a normal spine with no ankylosis, spasm, tenderness or laxity.  Cervical spine ROM measurements showed flexion from “0-60” degrees and a combined ROM of 315 degrees, after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 0%, analogously coded 5299-5241 (spinal fusion), citing good flexion and extension and almost full rotation without spasm or tenderness.  The VA also rated the neck condition 0%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing “forward flexion of the cervical spine greater than 40 degrees” with “mild or no effects on daily activities.”  Members deliberated over the probative value of the examinations in evidence focusing on the cervical spine ROM rating criteria.  The panel considered the “almost full” left and right rotation measurements in the NARSUM were most likely at least 5 degrees less than normal.  The panel also noted the VA combined ROM and the PT flexion measurements supported a 10% rating.  Although the PT combined ROM could support a 20% rating, it was adjudged as an outlier with earlier and later examinations showing greater combined ROM.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM greater than 170 degrees but not greater than 335 degrees, as reported on the NARSUM and VA 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.  There was no documentation of IVDS 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 recommends a disability rating of 10% for the neck condition, coded 5299-5241.  

Chronic Low Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition began in November 2002 after carrying a heavy desk up three flights of stairs.  The CI received lumbar spine epidural injections in February and May 2005.  The MEB NARSUM examination noted complaints of chronic low back pain with left leg numbness, pain and tingling.  Physical examination showed no spasm, but there was pain with flexion and extension.  Goniometric measurements were not provided, but the examiner recorded the CI could “bend down to about 60 degrees.”  

At the C&P examination, the CI reported progressively worsening low back pain radiating into the left leg.  Physical examination showed a normal spine with no ankylosis, laxity, swelling, effusion, spasm or tenderness.  The examiner recorded active flexion to 70 degrees (normal 90) with a combined ROM of 170 degrees (normal 240), after repetitive motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain), citing pain on flexion and extension.  The VA also rated the back condition 0%, but coded 5243, based on the C&P examination, citing a non-compensable evaluation for thoracolumbar spine forward flexion greater than 85 degrees or combined ROM greater than 235 degrees.  Members 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 on the PT, NARSUM and VA examinations.  Although the NARSUM flexion measurement of “about 60 degrees” might support a 20% rating, it was not a goniometric measurement and flexion was greater in examinations closer to separation.  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 IVDS 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 recommends a disability rating of 10% for the back condition, coded 5237  

Contended PEB Conditions:  Right Shoulder and Right Carpal Tunnel.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither of the conditions were profiled or failed retention standards.  Although both conditions were implicated in the commander’s statement, 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 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 bilateral knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  In the matter of the neck condition, the panel recommends a disability rating of 10%, coded 5299-5241 IAW VASRD §4.71a.  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 contended right shoulder and right carpal tunnel, 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 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	
Right Retropatellar Pain Syndrome	5099-5003	10%	
Left Retropatellar Pain Syndrome	5099-5003	10%	
Chronic Neck Pain	5299-5241	10%	
Chronic Low Back Pain	5237	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170317, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20190006829, 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 40% 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs