RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03167
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Health Care Specialist, medically separated for “low back pain” and “right knee pain,” rated 10% each, with a combined disability rating of 20%.  

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 - 20060403	VARD - 20070228	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Chronic Low Back Pain	5238	10%	20061114	
Right Knee Pain	5099-5003	10%	Right Knee DJD	5003-5260	10%		
Alopecia	Not Unfitting 	Alopecia	7899-7800	0%		
Hypothyroidism		Hypothyroidism	7903	10%		
COMBINED RATING:  20%	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 April 2004 after a recreational sports injury.  
During the 13 January 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported constant back pain.  Physical examination revealed a normal heel-to-toe walk.  Thoracolumbar range of motion (ROM) testing with a goniometer showed flexion to 90 degrees (normal) and combined ROM of 230 degrees (normal 240) limited by pain.  The 9 February 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of non-radiating low back pain worsened with any impact activities or heavy lifting.  Physical examination showed a mildly antalgic gait (attributed to the right knee), a normal appearing spine and tenderness of the lower back without noticeable spasm. 

At the 14 November 2006 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported constant, localized low back pain, rated 7/10 in severity, elicited by physical activity.  The CI denied incapacitating episodes, but described functional impairment as inability to bend, stand for long periods and slower walking.  Physical examination showed a normal gait, posture and spinal appearance without spasm or tenderness.  ROM testing recorded flexion of 90 degrees and combined ROM of 240 degrees without painful motion. 

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 tenderness.  The VA also rated the back condition 10%, coded 5238 (spinal stenosis), based on the C&P examination, citing “painful use.”  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) and painful motion, as noted at the MEB examination.  The 10% rating was also justified for the presence of tenderness noted on the NARSUM 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 documentation of intervertebral disc syndrome 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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Chronic Pain, Right Knee.  According to the STR and MEB NARSUM, the CI underwent right knee meniscal repair in 2004 with a second surgery in March 2005 to repair the anterior cruciate ligament (ACL).  The MEB examination revealed normal strength and neurologic functioning.  Painful motion was not addressed.  The MEB NARSUM examination noted complaints of continued right knee pain worsened with running, jumping or bending.  Physical examination showed a mild antalgic gait favoring the right lower extremity.  There was noticeable atrophy of the right quadriceps muscle, but no swelling, fluid buildup or discoloration of the knee.  Right knee ROM testing showed extension-to-flexion of 0-135 degrees (normal 0-140).  Testing revealed some ACL laxity (Level II A Lachman) and equivocal results for kneecap cartilage degeneration (patellar grind).  Painful motion was not addressed.  

At the 14 November 2006 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported constant right knee pain, rated 6/10 in severity, that prevented running.  Physical examination showed a normal posture and gait, with signs of right knee tenderness but no swelling, fluid buildup, weakness, redness or abnormal movement.  Right knee ROM was recorded as 0-140 degrees without painful motion.  All testing of the knee was normal.  Radiographic studies showed “minimal” degenerative changes to the knee.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee 10%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA also rated the right knee 10%, dual coded 5003-5260 (degenerative arthritis causing limitation of leg flexion), based on the C&P examination, citing “evidence of degenerative joint disease and tenderness.”  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), to support a rating under that code.  There was no objective evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 persistence of pain after meniscal surgery warrants a 10% rating under the 5259 code (cartilage, semilunar, removal of symptomatic), but that code change would provide no benefit to the CI.  There was therefore no higher rating than the PEB’s 10% rating under any applicable VASRD 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 right knee condition.  

Contended PEB Conditions:  Alopecia and Hypothyroidism.  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, implicated in the commander’s statement or judged to fail retention standards.  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 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 contended alopecia and hypothyroidism, 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.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

[AR NUMBER], 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.

Enclosure