RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02870
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050707

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Linguist Trainee, medically separated for “chronic low back pain,” rated 10%; and “right knee pain,” “chronic left knee pain” and “chronic right shoulder pain,” each rated 0%, 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 PEB - 20050502	VARD - 20060123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Lumbar Strain 	5237	10%	20050913	
Right Knee Pain	5099-5003	0%	Internal Derangement of Right Knee	5260-5259	10%	20050913	
Chronic Left Knee Pain	5099-5003	0%	Internal Derangement of left Knee 	5259-5261	10%	20050913	
Chronic Right Shoulder Pain	5099-5003	0%	Internal Derangement, Right Shoulder 	5201-5010	10%	20050913	
Migraine	Not Unfitting	Migraine Headaches	8100	30%	20050913	
Hypertension	Not Unfitting	Hypertension	7101	10%	20050913	
History of Retinal Tear, Right Eye	Not Unfitting	S/P Repair of Retinal Tear in Right Eye	6008	NSC	20050913	
Acne	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 2003 without trauma or incident.  The 21 January 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of “nearly unbearable pain.”  The physical examination was unremarkable.  There were no focal neurological deficits.  Lumbar range of motion (ROM) measurements revealed flexion of 50 degrees (normal 90) and combined range of motion of 155 degrees (normal 240).  

At the 21 March 2005 pain medicine consultation, 4 months prior to separation, the CI complained of lumbar and midline thoracic spine pain.  The gait was non-antalgic and the CI was able to walk on both heels and toes.  He presented in a slightly head forward, kyphotic position in the thoracic region.  Strength and sensory examinations were normal.  Lumbar flexion was “100% of normal” and extension was “100% of normal.”  

During the 13 September 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported daily back pain.  On examination, the CI had a normal coordinated gait and was able to tandem walk.  Spinal curvature was normal, but the lumbar spine was “somewhat tender to palpation.”  Lower extremity muscle strength was normal and sensory was intact.  Thoracolumbar active ROM measurements showed flexion of 90 degrees and combined ROM of 225 degrees, after repetition.  Painful motion was noted with extension.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing pain limited motion.  The VA also rated the back condition 10%, also coded 5237, based on the C&P examination, citing combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  

The limitation of motion recorded in the MEB NARSUM of 50 degrees, contrasted with the overall general physical examination that was unremarkable and the overall clinical picture as reported by pain management that showed a non-antalgic gait and ROM “100% of normal.”  The VA examination was significantly more detailed than the NARSUM and more proximate to separation.  Therefore, greater probative value was placed on the pain management and VA examinations.  The panel agreed that a 10% rating, but no higher, was justified for a combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on the VA C&P 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.  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 back condition.  

Right Knee Pain.  According to the STR and MEB NARSUM, the CI underwent arthroscopic debridement versus repair of meniscal tear surgery on 11 March 2004.  The MEB NARSUM examination, noted complaints of knee pain.  The general physical examination was unremarkable.  There was normal ROM without joint laxity and no focal neurological deficits.  However, there was tenderness over both knees. 

At the C&P examination the CI reported daily knee pain.  On examination, there was a normal coordinated gait and the CI was able to tandem walk.  There was tenderness at the anterior lateral aspect of the right knee.  Joints and muscles were symmetric without edema, masses or deformity.  There was no instability and muscle strength was normal.  Balance and sensory was intact.  The ROM study showed flexion of 125 degrees (normal 140) and extension of 0 degrees (normal) without pain.  X-rays from September 2005 were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing full ROM without instability.  The VA rated the right knee condition 10%, dual coded 5260-5259 (leg, limitation of flexion-cartilage, semilunar, removal of, symptomatic), based on the C&P examination, citing limitation of motion.  

There was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) and the panel noted there was no evidence of painful motion with functional loss supporting a 10% rating based on §4.59, §4.40 and §4.45.  There was no history or evidence of dislocated semilunar cartilage causing frequent locking with recurrent effusions (5258) or semilunar cartilage removal (5259).  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).  Therefore, the panel concluded there was insufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  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 right knee condition.  

Chronic Left Knee Pain.  According to the STR and MEB NARSUM, the CI underwent laparoscopic partial left knee meniscectomy on 15 October 2001 while at the United States Military Academy Preparatory School.  He received a waiver for his left knee and enlisted in the Army in September 2002.  Although his left knee was symptomatic at the time, he “toughed it out” and completed basic training.  He also passed the APFT in February 2003.  A left knee MRI on 14 April 2004 revealed a strain of the vastus medialis muscle and tendon, medial collateral ligament strain, small effusion, post-surgical changes in the anterior horn of the lateral meniscus, but no medial meniscal tear.  

The MEB NARSUM examination noted complaints of left knee pain.  Physical examination showed tenderness, but ROM was normal without joint laxity and there were no focal neurological deficits.  At the C&P examination the CI reported daily left knee pain.  The gait was normal, but there was tenderness at the lateral anterior aspect of the left knee.  There was no instability.  The ROM study showed flexion of 125 degrees and extension of 0 degrees without pain.  X-rays were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, analogously coded 5099-5003, citing no loss of motion.  The VA rated the left knee condition 10%, dual coded 5259-5261 (cartilage, semilunar, removal of, symptomatic/leg, limitation of extension of), based on the C&P examination, citing limitation of motion.  The panel noted there was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise 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 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).  However, the panel noted there was evidence supporting a 10% rating under the analogous VASRD code 5299-5259 for partial left knee meniscectomy with objective signs of pain on palpation and subjective complaints of knee pain.  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 left knee condition, coded 5299-5259.  

Chronic Right Shoulder Pain.  According to the STR and MEB NARSUM, the CI underwent laparoscopic repair of a SLAP (superior labral from anterior to posterior) tear in November 2003.  The MEB NARSUM examination noted complaints of chronic right shoulder pain.  Physical examination showed tenderness over the right acromioclavicular joint and short head of the biceps tendon.  There was normal ROM with slight decrease in strength due to pain.  Apprehension or sulcus signs were absent.  

At the VA C&P examination, the CI reported daily right shoulder pain.  Physical examination showed tenderness.  There was no winging of the scapula.  Joints and muscles were symmetric without edema, erythema, masses or deformity.  There was no laxity and balance and sensory was intact.  The ROM evaluation showed flexion of 180 degrees (normal) and abduction of 180 degrees (normal) with pain and crepitus.  X-rays were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, analogously coded 5099-5003, citing full ROM without joint instability.  The VA rated the right shoulder condition 10%, dual coded 5201-5010 (arm, limitation of motion of-arthritis, due to trauma), based on the C&P examination, citing limitation of arm motion on repeated use or during flare-ups there would be a 15-degree loss in ROM.  

The panel agreed that the evidence of record supports a 10% rating for painful motion with crepitus IAW VASRD §4.59, §4.40 and §4.45.  There was no evidence of limited arm motion at shoulder level (5201); impairment of the clavicle or scapula (5203); humerus impairment with moderate deformity or recurrent subluxations (5202); or, shoulder ankyloses (5200).  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 right shoulder condition, coded 5099-5003.  

Contended PEB Conditions:  Hypertension, Right Eye Retinal Tear and Acne.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of these conditions were profiled or judged to fail retention standards.  There was no performance-based evidence from the record that any of these 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 any of the contended conditions, so no additional disability ratings are recommended.  

Contended PEB Condition: Migraine.  As above, the panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The STR indicates an extensive history of migraine headaches dating back to age 17.  Although the headaches were profiled, judged by the MEB to fail retention standards and implicated in the commander’s statement, evidence of characteristic prostrating headaches that resulted in extreme exhaustion and powerlessness were not appreciated.  In February 2005, the neurologist recorded the CI’s “episodic migraine headaches” responded well to preventative medication (Topamax).  The examiner recorded, “he thinks his headaches have been controlled and have decreased in frequency from the past.”  The STR showed evidence of only three headaches from the February 2005 neurology examination until separation in July 2005.  Although symptomatic, there was no performance-based evidence from the record that the migraine 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 of the migraine headaches, so no additional disability rating is recommended.  

BOARD FINDINGS:  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 right knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5299-5259 IAW VASRD §4.71a.  In the matter of the right shoulder condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended migraine headaches, hypertension, acne and right eye retinal tear, 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	
Chronic Low Back Pain	5237	10%	
Chronic Right Shoulder Pain	5099-5003	10%	
Right Knee Pain	5299-5259	0%	
Chronic Left Knee Pain	5099-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008786, 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 30% 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.

Sincerely,					      
Enclosure