RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2017-03368
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050506

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

CI CONTENTION:  In addition to his back condition, the CI requested review of his left knee pain which was identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) and determined to be not unfitting. He also requested review of post-traumatic stress disorder (PTSD) and insomnia, neither of which were identified by the MEB and PEB.  

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 – 20050412	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5299-5237	10%	No VA Examination Proximate to Separation in Evidence	
Chronic Left Knee Pain	Not Unfitting		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic LBP.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in May 2004 after a rough parachute landing.  The CI reported immediate sharp pain in his lower back.  X-rays of the thoracic spine in October 2004 were normal and X-rays of the lumbar spine showed bilateral L5 spondylolysis (separation or fracture of the pars interarticularis) with Grade II anterior spondylolisthesis [forward sliding of a vertebra over the one below it) of L5 on S1.  An MRI in November 2004 showed an L4-L5 disk bulge and osteophyte complex without canal or foraminal stenosis and an L5-S1 broad-based disk bulge and osteophyte complex with bilateral L5 spondylolysis with grade I L5 on S1 anterolisthesis with bilateral moderate to severe foraminal stenosis and no significant central canal stenosis. 

During the 10 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported an inability to sleep due to back pain.  Physical examination revealed a positive straight leg raise (SLR) test on the right (to determine nerve root irritation), an intact neurological examination, no bowel or bladder dysfunction, no clonus (involuntary alternating muscle contractions and relaxations, spasticity, or Babinski reflex (to indicate an upper motor neuron lesion), and no muscle wasting.  Pain was noted with right rotation and right side motion.  

The 14 March 2005 MEB NARSUM examination, 2 months prior to separation, noted an inability to continue with daily activities within his military occupational specialty.  Physical examination showed a positive SLR on the right and pain with flexion, extension, and rotation to the right.  The CI received a combination of a long acting anesthetic/steroid injection to the right sacroiliac joint for pain relief on 12 April 2005.  There was no VA examination proximate to separation in evidence.

At the 8 June 2005 family health clinic examination, one month after separation, the CI reported that the chiropractic therapy was not helpful.  Pain was described as a sharp sensation in the lower back with radiation of numbness down the right leg to the level of the mid-thigh.  Physical examination showed no deformities, no spinal or costovertebral angle tenderness, a slight increase in muscle tone in the lumbar paraspinal muscles, normal deep tendon reflexes, and a positive SLR test on the right.  The CI was prescribed Naprosyn (a nonsteroidal anti-inflammatory drug (NSAID)) and Baclofen (for muscle spasms).  At an initial history and physical examination on 3 August 2005, 3 months after separation, examination of the head, neck, back, and extremities revealed the ROM was essentially within normal limits and was negative for trigger points, spasm, or atrophy.  X-rays 2 days later demonstrated a pars defect at the L5 level with associated grade II spondylolisthesis of L5 on S1.  An MRI dated 8 August 2005 showed findings similar to prior MRIs.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP 10%, analogously coded 5299-5237 (lumbosacral strain), citing normal muscle strength, reflexes and sensation with ROM at 60 degrees flexion and extension at 15 degrees.  The PEB determined the rating based on a passive ROM measurement rather than an active ROM measurement for flexion.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but less than 60 degrees) as reported on the PT examination prior to separation.  There was no documentation of intervertebral disc syndrome (IVDS) 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 recommends a disability rating of 20% for the chronic low back condition, coded 5239-5243 (spondylolisthesis or segmental instability - (IVDS).  

Contended PEB Condition:  Chronic Left Knee Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was profiled and implicated in the commander’s statement, and did fail retention standards.  According to the STR and MEB NARSUM, the CI’s left knee injury occurred in May 2004 when he slipped down a hill and hyperextended his left knee during a road march.  An MRI in May 2004, showed increased T2 signal intensity of the anterior cruciate ligament (ACL).  A strain or partial tear of the ACL could not be excluded.  Treatment included a profile, an NSAID, and PT, where the ROM was 0-140 degrees (normal) with pain on flexion.  The knee did not improve and the CI complained that his knee “gives out” while ascending or descending stairs.  

At the 10 January 2005 MEB examination, there was a mild effusion, a positive drawer test (to determine instability), stable medial and lateral ligaments, and no pain with motion.  At the 21 January 2005 PT examination, left knee active flexion was 120 degrees and extension was 0 degrees (normal).  The 14 March 2005 NARSUM physical examination showed a mild effusion and positive drawer test with no pain on motion.  At the family health clinic visit on 8 June 2005, one month after separation, the CI reported pain behind the patella which was diagnosed as patellofemoral syndrome.  Physical examination showed the left knee with no ligamentous instability, effusion, or deformity, and no history of leg weakness was reported. There was performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  

After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of the left knee condition favors its recommendation as an additionally unfitting condition for disability rating.  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).  The panel considered other VASRD knee and analogous codes, but all were less applicable and not advantageous for rating.   No additional functional limitation was evidenced by the examinations most proximate to separation.  The panel concluded there was insufficient evidence to support a rating higher than the 0%.  Therefore, the chronic left knee pain is appropriately analogously coded 5099-5003 and meets the VASRD §4.71 criteria for a 0% rating due to no objective painful motion proximate to separation.

BOARD FINDINGS:  In the matter of the chronic low back condition, the panel recommends a disability rating of 20%, coded 5239-5243 IAW VASRD §4.71a.  In the matter of the contended chronic left knee pain condition, the panel agrees it was unfitting and recommends a disability rating of 0%, coded 5099-5003 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5239-5243	20%	
Chronic Left Knee Pain	5099-5003	0%	
COMBINED	20%	

The following documentary evidence was considered:

, XXXXXXXXXXXXXX

Dear XXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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Enclosure