RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03934
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060702

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O1, Health Services Administrator, medically separated for “chronic back pain” and “bilateral knee pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  No specific contention was made.  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 - 20060411	VARD - 20061222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5242	10%	Lumbar Strain S/P Herniated Disc	5237	20%	20061031	
Bilateral Knee Pain	5099-5003	0%	Left knee Patellar Femoral Pain Syndrome	5014	10%	20061031	
			Right Knee Patellar Femoral Pain Syndrome	5014	10%	20061031	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in June 2005 without specific trauma or injury.  An MRI showed mild disc bulging at L4-5, but there was no surgical indication.  The 24 March 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of back pain.  The range of motion (ROM) study showed flexion of 55 degrees (normal 90) and combined ROM of 190 degrees (normal 240).  On examination, tenderness was noted.  

At the 31 October 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported daily stiffness, weakness and constant 9/10 pain radiating down to the legs.  Physical examination showed normal posture and gait.  There was no evidence of radiating pain on movement or muscle spasm, but there was tenderness.  The ROM study showed flexion of 55 degrees (normal 90), with pain, and combined ROM of 165 degrees (normal 240), with pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded as 5242 (degenerative arthritis of the spine) citing ROM limited by pain with localized tenderness.  The VA rated back condition 20%, coded 5237 (lumbosacral strain), based on the C&P examination, citing flexion of thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  

The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the NARSUM and VA examinations.  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 back condition, coded 5299-5242.  

Bilateral Knee Pain.  The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5099-5003 (degenerative arthritis) and rated 0%.  The 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 also 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 the PEB’s approach of 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.  The evidence for the left and right knee conditions is presented together with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record STR and MEB NARSUM, the CI’s bilateral knee pain began in June 2005 without specific trauma or injury.  X-rays were normal and there was no surgical indication.  The MEB NARSUM ROM examination, 4 months prior to separation, showed right knee flexion of 150 degrees (normal 140), left knee flexion of 145 degrees and extension of 0 degrees (normal); painful motion was not present in either knee. 

At the C&P examination the CI reported 7/10 bilateral knee pain with weakness, stiffness, swelling, redness, giving way, locking and lack of endurance.  Physical examination showed bilateral knee tenderness.  The ROM study showed bilateral flexion of 140 degrees, with pain at 140 degrees, and bilateral extension of 0 degrees.  Neither knee was additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  Provocative testing to elicit instability or meniscal pathology was negative bilaterally.  

The panel first considered if the left and right knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel concluded there was not a preponderance of evidence in the service records which overcame the presumption that the bundled left and right knee conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting left and right knee conditions at the time of separation.  The PEB rated the bilateral knee condition 0%, analogously coded as 5003, citing no ratable limitation of motion.  The VA rated each knee 10%, coded 5014 (osteomalacia) based on the C&P examination, citing painful or limited motion of a major joint.  

Panel members noted that both knees were discussed together and neither knee was identified as more severe.  Both knees demonstrated full ROM and bilateral ligament examinations were normal.  Although the post-separation VA examination reported “pain at 140 degrees,” the MEB NARSUM reported 0/10 pain during ROM testing.  X-rays of the both knees were normal.  The panel concluded that separately rating each knee condition would not result in a rating advantage to the CI.  Therefore, 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 bilateral knee condition.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5299-5242 IAW VASRD §4.71a.  In the matter of the bilateral 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.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5299-5242	20%	
Bilateral Knee Pain	5099-5003	0%	
COMBINED	20%	

AR20180015895, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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.
A copy of this decision has also been provided to the Department of Veterans Affairs.