RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03345
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Chemical Operations Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  Review the rating for his left knee and review the PTSD and back conditions.  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 - 20090312	VARD - 20090915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	10%	Left Knee Degenerative Arthritis	5261-5003	10%	20090819	
Anxiety	Not Unfitting	Post-Traumatic Stress Disorder	9411	70%		
		Anxiety Disorder	9413	NSC		
Low Back Pain		Lumbar Spine Strain	5237	20%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI underwent arthroscopic surgery on 28 September 2007, which identified and debrided a degenerative tear of the medial meniscus.  The pain persisted and he was referred for MEB.  There were numerous post-operative STR clinical entries that documented improving range of motion (ROM), with later entries recording flexion in the 120-130 degree range (normal 140) with 0 degrees extension (normal).  There was documentation of a normal gait without persistent effusion or meniscal impingement (locking). 

At the 3 September 2008 MEB NARSUM examination, 9 months prior to separation, the CI complained of persistent pain rated 7/10 that prohibited walking (1/4 mile tolerance), prolonged standing, heavy lifting or load bearing.  The physical examination recorded some non-specific “gait issues,” no effusion and no note of impingement or locking.  The 15 May 2008 physical therapy ROM study was quoted by the examiner and recorded goniometric ROM measurements of 135 degrees of flexion and 5 degrees of extension (likely baseline hyperextension with identical measurement for left knee).   

The CI underwent diagnostic arthroscopy on 14 January 2009 (4 months before separation).  No significant pathology was identified and no further surgical intervention was indicated.  An orthopedic note, a week after the procedure, documented flexion of 90 degrees and extension of 0 degrees.  

During the VA Compensation and Pension (C&P) examination on 14 August 2009 (3 months after separation) and C&P examination on 19 August 2009 (different examiners, both cited in evidence for rating decision, no explanation), the CI reported “daily” pain rated 5/10 that was aggravated by exercising, prolonged standing or running.  Both examiners recorded a normal gait and neither specified the presence of an effusion or impingement.  One examiner recorded flexion to 135 degrees and the other to 140 degrees (specifying painful motion), and both noted extension of 0 degrees.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing pain and limitation of motion.  The VA also rated the condition 10%, dual coded 5261-5003 (limitation of extension due to degenerative arthritis), citing painful motion.  There was no evidence for compensable limitation of motion (codes 5260 or 5261), persistent effusion and locking (code 5258), or fracture with nonunion or malunion (code 5262) to support a rating higher than 10%.  There were no other applicable coding or rating options.  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 of the left knee condition.

Contended PEB Condition:  Anxiety.  The panel carefully reviewed the evidence relevant to the disparity between the service diagnosis and the diagnosis of PTSD as contended by the CI and rated by the VA.  The CI presented to mental health (MH) services with some symptoms consistent with PTSD after redeployment, and there were numerous MH entries in the STR that acknowledged and addressed these symptoms.  The Axis I diagnosis in all of these entries (including by clinical psychologists and a psychiatrist) was initially adjustment disorder and subsequently anxiety disorder.  The single exception was a diagnosis of chronic PTSD by a social work counselor late in the course.  The NARSUM and the MEB’s DA Form 3947 listed anxiety as the only MH condition.  The STR clinical entries portrayed an improving course and a stable psychiatric condition controlled by medication and outpatient therapy.  The commander’s performance statement did not implicate a MH condition.  The profile was S1 and the anxiety condition was judged to meet retention standards.

The post-separation C&P examination of 14 August 2009 documented stable psychiatric symptoms and a diagnosis of adjustment disorder; but a psychiatric C&P examination soon afterwards (11 July 2009) documented the CI’s endorsement of each diagnostic criterion for PTSD with more severe overall symptoms than those previously documented.  The mental status examination was significant only for an anxious mood.  Detailed cognitive testing was normal and the CI had just commenced employment in a technical position.  The Axis I diagnosis was “PTSD, chronic” and the severity was characterized as “moderate” (global assessment of functioning - 55).  

The panel’s main charge is to assess the fairness of the PEB determination that the MH condition (irrespective of diagnosis) was not unfitting.  Although the CI may have manifested some MH symptoms at separation, there was no performance-based evidence from which to conclude that there was MH impairment severe enough to preclude retention.  This conclusion was convincingly supported by the profile, commander’s statement and MEB opinion that the condition met retention standards.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the anxiety disorder (or any alternate psychiatric diagnosis), and no additional disability rating is recommended.  

Contended PEB Condition:  Low Back Pain.  The CI developed a complaint of left-sided low back pain that he dated to the same incident in Iraq resulting in his knee pain.  Imaging demonstrated degenerative disc disease, but a nerve study was normal and surgery was not recommended.  The NARSUM characterized the condition as “low back pain secondary to gait disturbance secondary to the knee” and it was judged to meet retention standards.  It was not profiled.  The commander’s performance statement referenced “extreme pain [in] lower back and left leg,” but the listed limitations (heavy carrying, road marching and continuous strenuous activity) were not specific to the spine.   

As with the anxiety condition, the panel’s main charge is to assess the fairness of the PEB fitness determination; and, given the above performance-based evidence, members agreed that there was insufficient cause to recommend a change in the PEB fitness determination for the back condition.

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended mental health and lumbar conditions, 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, therefore, recommends that there be 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 20170404, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008931, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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.

Sincerely,					      
Enclosure