RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02831
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090723

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

CI CONTENTION:  No specific contention was made.  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 - 20090604	VARD - 20100406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Thoracolumbar Spine DDD 	5243	10%	20091215	
Left Knee Pain	5257	10%	Status Post Left Knee Arthroscopic Surgery	5299-5260	10%	20091215	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began gradually during the winter of 2005 after a day of heavy cleaning his garage.  Pain was reported as sharp and stabbing in the lower back and radiating to the upper back between the shoulder blades.  The CI improved enough to deploy, but began to experience increased back pain from wearing his body armor for many hours.  Upon return from his deployment a lumbar MRI in March 2008 showed degenerative disc disease (DDD) and a thoracic MRI in May 2008 showed DDD, with contact with the spinal cord.  A neurosurgical consult did not recommend surgery.  Further treatment included injections and physical therapy (PT), neither providing relief of duty limitations.  PT measured thoracolumbar range of motion (ROM) for the MEB on 27 October 2008, 9 months prior to separation, and after three repetitions flexion was 80 degrees (normal 90) and combined ROM was 190 degrees (normal 240).  Painful motion was not addressed.  During the 12 February 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported back pain with sitting, standing or laying down too long.  Physical examination showed tenderness of thoracic paraspinal muscles, the lumbosacral junction and the right sacroiliac joint.  

The 11 May 2009 MEB NARSUM examination, 2 months prior to separation, noted complaints of upper and lower back pain.  Pain, reported as constant but worsening at night, was precipitated by impact activities and bending, lifting, or wearing gear.  Physical examination noted ROM measured by PT and then the MEB physician was minimally changed.  Thoracolumbar ROM after three repetitions was recorded as flexion of 100 degrees (normal 90) with pain beginning at 80 degrees and combined ROM was 225 degrees, with pain limited combined ROM at 185 degrees.  The MEB NARSUM examiner commented that functional limitation of motion due to pain could be expected to approach the points at which pain began as noted above in the PT MEB examination.  

At the 15 December 2009 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported decreased motion, stiffness, spasms and back pain.  Pain was aggravated by prolonged walking, standing or overexertion.  The CI denied incapacitating episodes due to the back condition.  Physical examination showed a normal gait.  There was no evidence of abnormal spinal curvatures or guarding.  There was tenderness, muscle spasm, and pain with motion.  Thoracolumbar flexion was 90 degrees with combined ROM of 240 degrees.  There was objective evidence of pain with repetitive motion without additional loss of ROM.  Spine X-rays showed mild to moderate degenerative disease.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back pain 10%, coded 5237 (lumbosacral strain), citing forward flexion to 80 degrees with combined ROM at 190 degrees.  The VA also rated the chronic back pain 10%, coded 5243 (intervertebral disc syndrome [IVDS]), based on the C&P examination, citing objective evidence of painful motion.  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) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the PT MEB and MEB NARSUM examinations and the painful motion and tenderness noted at 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 evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  After due deliberation, considering all 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 chronic back condition.   

Left Knee Pain.  According to the STR and MEB NARSUM, the CI’s left knee pain began in 2001 following a twisting injury while doing maintenance on trucks and was followed by repetitive twisting injuries.  The CI underwent an arthroscopy without debridement or repairs.  Following PT, the knee improved.  In November 2003, during grenade training, the CI hit his lateral knee resulting in swelling, but X-rays were negative and it resolved on its own.  The CI then reinjured his knee while deployed when he jumped out of a truck onto a sandy surface, tore his anterior cruciate ligament (ACL) and was medically evacuated for surgery (May 2004).  Following surgery, physical limitations continued.  PT measured left knee ROM for the MEB 9 months prior to separation, and after three repetitions flexion was 121 degrees and extension was 0 degrees; there was no change with repetition.  The therapist noted evidence of instability with a 1+ B Lachman’s (mild anterior translation with testing without a firm endpoint).  A MEB request for orthopedic consult in February 2009 indicated complaints of intermittent knee pain with a feeling of patellar dislocation.  

At the MEB orthopedic consult on 3 March 2009, 5 months prior to separation, physical examination of the knee showed instability with positive Lachman’s and pivot shift tests.  There was no effusion, deformity or tenderness and ROM was normal.  Patellofemoral grind testing was negative as were gait and stance.  Knee X-rays showed no degenerative changes; changes from the ACL surgery were noted, but surgical hardware was not.  At the 11 May 2009 MEB NARSUM examination, 2 months prior to separation, knee ROM after three repetitions showed flexion of 121 degrees and extension at 0.  There was a 2+ Lachman’s (significant ACL instability).  The MEB NARSUM examiner noted the CI had recently discovered there was a surgical option for his left knee.  He desired to postpone surgery as long as possible and wanted to wait until after leaving active duty.  

At the C&P examination the CI reported his left knee giving way, instability, stiffness, decreased motion, and flare-ups of moderate severity every 2 to 3 weeks.  He reported he was able to walk 1 to 3 miles and there had been no periods of incapacitation due to the knee condition.  Physical examination showed normal gait, no crepitation, clicks or snaps, grinding, instability or other abnormalities.  Active ROM showed flexion at 135 degrees and extension at 0 degrees.  There was objective evidence of pain following repetitive motion, but there was no additional loss of ROM.  Knee X-rays showed mild degenerative changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee pain condition 10%, coded 5257 (knee, other impairment), citing non-compensable ROM with slight knee impairment.  The VA also rated the status post left knee arthroscopic surgery condition 10%, analogously coded as 5260 (leg, limitation of flexion), based on the C&P examination, citing objective evidence of painful motion.  There was evidence of recurrent instability following ACL repair and the panel agreed a 10% rating and no higher was supported for slight knee impairment, coded 5257 based on the CI’s MEB orthopedic consult which noted instability with good motion, no tenderness or effusion and a normal gait.  There was no limitation of motion which supported a 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 support a 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).  There was therefore no VASRD §4.71a rating higher than 10% under any applicable code.  After due deliberation, considering all 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.   

BOARD FINDINGS:  In the matter of the chronic back condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the left knee condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  There are 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 20170303, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190008801, XXXXXXXXXXXXXXXXXX

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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.