[AR NUMBER], XXXXXXXXXX

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

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.

Enclosure

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03158
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060708

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Motor Transport Operator, medically separated for “bilateral knee pain and bilateral elbow pain” and “chronic neck pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20060502	VARD - 20070222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain and Bilateral Elbow Pain	5099-5003	10%	Mild Degenerative Changes Bilateral Elbow, Bilateral Knee, Cervical Spine and Low Back	5003	10%	20061028	
Chronic Neck Pain	5299-5237	0%					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain and Bilateral Elbow Pain.  The PEB combined the bilateral knee and the bilateral elbow conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  This 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 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 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.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-handed CI’s bilateral knee pain began in September 2001 after repeatedly jumping off the back of 5-ton trucks.  MRIs documented meniscal injuries and he underwent left knee meniscal debridement with chondroplasty in June 2004, and right knee meniscal debridement in March 2005.  The CI’s bilateral elbow condition began in July 2003 after driving with Kevlar and body armor, with additional elbow and arm pain following a motor vehicle crash (MVC).  

The 2 March 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic bilateral knee pain and chronic bilateral elbow pain.  Physical examination showed tenderness and crepitus, with pain limited range of motion (ROM) as charted below.  During the 13 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported bilateral knee pain with use of a hinged brace; and bilateral elbow pain.  Physical examination revealed bilateral knee effusions with tenderness, crepitus, and patellar grind.  There was bilateral elbow tenderness.  Occupational therapy evaluation on 20 April 2006 recorded decreased grip strength [on the right of 20(-70) and left 46(-47)]  

At the 28 October 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported bilateral knee and bilateral elbow pain.  X-rays showed degenerative changes in both knees and both elbows.  Physical examination showed a normal gait.  ROMs are charted below for the knees and elbows.  Pain was specifically noted on right knee ROM, with bilaterally positive McMurray’s tests for meniscal pathology.  

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Knee ROM
(Degrees)	MEB ~4 Mo. Pre-Sep	VA C&P ~4 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	80	95	130	120	
Extension (0 Normal)	-	-	0	0	
Comment	With pain; tenderness; crepitus	With pain; tenderness; crepitus	No pain; +effusion; +McMurray’s	Pain at 120; +effusion; +McMurray’s	
§4.71a Rating	10%	10%	10%	10%	

Elbow ROM
(Degrees)	MEB ~4 Mo. Pre-Sep	VA C&P ~4 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (145 Normal)	115	120	145	145	
Extension (0)	-	-	full	full	
Comment	With pain	With pain	No loss of motion on repetitive use; Exquisite tenderness to palpation	
§4.71a Rating	10%	10%	0%	0%	
			Together 10% analogous to 5003	

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the bilateral knees with bilateral elbows and applied a single 10% rating (coded 5099-5003) citing knee and elbow ROM limited by pain with application of the US Army Physical Disability Agency pain policy.  The VA rated the mild degenerative changes in the bilateral elbow, bilateral knee, cervical spine and low back combined at 10%, coded 5003, based on the C&P examination, citing normal ROMs and “a 10 percent evaluation is assigned for painful or limited motion of a major joint or group of minor joints, and may also be applied once to multiple joints if there is no limited or painful motion.”  

The U3L3 profile listed “chronic pain B/L (bilateral) elbows, knee neck back” with restrictions of no ability to carry/fire a weapon, move with a fighting load, do 3-5 second rushes, and added restrictions of “no run, jump, ruck march, no impact activities.”  The commander separately implicated “1) chronic pain both elbows 2) chronic pain in knees ….”  

The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee or either elbow over the other.  The knees each had meniscal surgery and the elbow both had X-ray evidence of degenerative joint disease.  Although there was likely additional overlap of the painful elbow joints with neuropathic conditions, any neuropathic contribution is outside of the scope of the PDBR.  Since undue speculation would be required to conclude that impairment from either knee or elbow joints would not have unacceptably interfered with the performance of military duties, members agreed that each elbow and knee was reasonably justified as separately unfitting.  The panel adjudged that the NARSUM examination had the highest probative value for rating at separation.  

Regarding rating of the unfitting knees, each knee had meniscal surgery, similar pathology, and similar clinical and ratable finding; therefore their ratings are similar.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under that code.  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, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) based on the NARSUM examination.  The analogous 5259 code (cartilage, semilunar, removal of, symptomatic) was alternatively supported in this case, by the VA findings of residual knee symptoms and findings of meniscal pathology.  

Regarding rating of the unfitting elbows, each had similar pathology, and similar clinical and ratable finding; therefore their ratings are similar.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5206, 5207, 5208, or 5213).  There was no history or evidence of ankylosis, fractures, or malunion.  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each joint based on the NARSUM examination.  Roding analogous to 5259 (meniscal), 5003 (degenerative), and 5260 (limitation of flexion with §4.59) was considered and code 5299-5260 was predominant.  

After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5299-5260; and a disability rating of 10% for the right elbow condition and 10% for the left elbow condition, each coded 5099-5003.  

Chronic Neck Pain.  According to the STR and MEB NARSUM, the CI’s neck condition began in 2002 with a MVC and in July 2003 after with his elbow pain during driving with Kevlar and body armor with additional pain another MVC.  MRI in June 2004 showed central canal stenosis from C3/4 through CS/6 by disk osteophyte complex effacing the thecal sac but no cord encroachment.  

The 2 March 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic neck pain associated with bilateral arm pain.  Physical examination showed pain-limited cervical ROM as charted below.  MRI was reported as revealing multi-level spondylitic changes without core compression or central canal stenosis.  However, spurring resulted in multi-level bilateral foraminal narrowing most pronounced on the right at C5-6 and on the left at C6-7.  

At the 28 October 2006 VA C&P evaluation, 4 months after separation, the CI reported neck pain, decreased motion, stiffness, weakness, and spasms.  X-rays showed degenerative changes with moderate disc space narrowing.  The examiner found a normal gait and posture.  There was cervical muscle spasm and tenderness.  ROMs were limited with painful extension as charted below.  

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Cervical ROM
(Degrees)	NARSUM ~4 Mo. Pre-Sep	VA ~4 Mo. Post-Sep	
Flexion (45 Normal)	40	45	
Combined (340)	270	320	
Comments	Painful motion	Painful extension; spasm; tender	
§4.71a Rating	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, analogously coded 5099-5003, citing cervical ROM limited by pain.  As noted above, the VA combined the neck condition with the back and bilateral knees and elbows for a single 10% rating.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) on the NARSUM examination or combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on all of the examinations proximate to separation.  Alternatively, there was sufficient evidence of painful motion on all examinations to warrant a 10% rating.  It was noted that muscle spasm was present on the VA examination, however there was not an associated abnormal gait or abnormal spinal contour to support the next higher rating of 20% (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  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 neck condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the bilateral knees and bilateral elbows condition, the panel unanimously recommends that each joint be separately adjudicated as follows:  an unfitting right knee condition coded 5299-5260 and rated 10%; an unfitting left knee condition, coded 5299-5260 and rated 10%; an unfitting right elbow condition coded 5099-5003 and rated 10%; and an unfitting left elbow condition, coded 5099-5003 and rated 10%; all IAW VASRD §4.71a.  In the matter of the neck condition, the panel recommends a disability rating of 10%, coded 5299-5237, IAW VASRD §4.71a.  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	
Bilateral Knee Pain and Bilateral Elbow Pain	Left Knee	5299-5260	10%	
	Right Knee	5299-5260	10%	
	Left Elbow	5099-5003	10%	
	Right Elbow	5099-5003	10%	
Chronic Neck Pain	5299-5237	10%	
COMBINED	40%	

The following documentary evidence was considered: