RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03437
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “chronic low back pain” and “left patellar tendonitis,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

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 - 20051212	VARD - 20060113	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	10%	Herniated Lumbar Disc L5-S1	5243	20%	20051027	
			Radiculopathy (S1), Left Leg 	8699-8620	10%	20051027	
Left Patellar Tendonitis	5024	0%	Left Patellar Tendonitis	5099-5024	10%	20051027	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began after his HMMWV hit an IED in June 2002, but he was able to complete his tour.  The back condition was aggravated during a deployment to Iraq in 2003, but the CE was again able to finish his deployment.  He was evaluated by neurosurgery in 2005, but no correctible lesion was found.  The 15 August 2005 CT scan revealed a mild disc bulge at L4-5 and spina bifida occulta was present.  There was no spinal canal stenosis or neural foraminal stenosis.  The 18 August 2005 neurosurgery evaluation, 5 months prior to separation, the CI presented for follow-up evaluation.  Physical examination showed a normal gait and station.  Motor strength was normal.   

The 9 September 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of severe low back pain with pain and numbness in the left leg.  Physical examination showed diffuse tenderness.  Goniometric thoracolumbar range of motion (ROM) testing showed forward flexion of 35 degrees (normal 90) and combined ROM of 110 degrees (normal 240), after repetitive motion, with painful motion.
 
At the time of the neurology clinic appointment on 20 September 2005, 4 months prior to separation, the CI reported low back pain with tingling down the left leg.  Physical examination showed a left sided antalgic gait, but heel-to-toe walking and tandem gait were normal.  Tenderness was present and there was spasms of the left paraspinal muscles, but the lumbosacral spine exhibited a normal appearance.  The motor examination revealed normal bulk, tone and strength.  Straight leg test was negative, bilaterally.  Deep tendon reflexes were normal.  Electrodiagnostic (EMG) testing from September 2005 revealed a normal study of the bilateral lower extremities.  

At the 27 October 2005 VA Compensation and Pension (C&P) examination, approximately 2 months before separation, the CI reported constant pain (6/10) located at the lower left side of his back that traveled down his left hamstring to his calf.  He stated the condition had never caused incapacitation.  Physical examination revealed the CI’s gait and posture were within normal limits (WNL).  Tenderness was present, but muscle spasm was absent.  There were no complaints of radiating pain on movement.  Muscle strength was WNL.  Straight leg test was negative, bilaterally, but there was decreased sensation to the lateral left calf.  Thoracolumbar ROM showed flexion of 80 degrees and combined ROM of 230 degrees with painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome), citing ROM limited by pain, tenderness and spasm.  The VA rated the back condition 20%, coded 5243, based on the C&P examination.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the VA C&P examination.  The panel noted the MEB ROM of 35 degrees of forward flexion, but placed more probative value on the VA examination because of its proximity to separation.  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.  

Left Patellar Tendonitis.  According to the STR and the MEB NARSUM, the CI’s left knee condition began in April 2000 during basic training.  He was seen by orthopedics in May 2004 and was informed that his knee was not surgically correctible.  During the 7 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported left knee pain and swelling when running and walking long distances.  Physical examination showed crepitation of the left knee over the tibial tubercle.  ROM of the left knee was full.  The 9 September 2005 MEB NARSUM examination, 2 days later, noted complaints of intermittent pain in the tibial tubercle on the left knee.  Physical examination showed tenderness and swelling over the left tibial tubercle.  ROM of the left knee was normal.  

At the C&P evaluation the CI reported left knee stiffness with difficulty walking at times.  Physical examination showed the gait and posture WNL.  There was a tender anterior tibial tubercle on the left side.  Instability and meniscal pathology tests were negative.  The ROM study of the left knee showed flexion of 140 degrees (normal) and extension of 0 degrees (normal).  Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  X-rays showed bony hypertrophy and incomplete calcification of the left anterior tibial tubercle.  

The 25 July 2006, orthopedic surgery consultation, 6 months after separation, the CI reported soreness just below the left knee cap.  Physical examination showed some prominence of the left tibial tubercle.  There was no swelling, no patellar tendon thickness or palpable soreness.  The knee was stable with full ROM.  The left hip also demonstrated full ROM.  The orthopedic surgeon noted the CI had a past diagnosis of Osgood/Schlatter’s and stated an attempt at surgical excision would likely be of no benefit.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded 5024 (tenosynovitis), citing normal ROM.  The VA rated the left knee condition 10%, analogously coded 5024, based on the C&P examination.  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 history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those codes.  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).  No additional functional limitation was evidenced by the examinations.  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 left knee condition.  

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 left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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:  

Exhibit A.  DD Form 294, dated 20170402, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20180009127, 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