RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04454
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Precision Measurement Equipment Laboratory Journeyman, medically separated for “chronic back pain” and “knee pain,” rated 0% each, with a combined disability rating of 0%.   

CI CONTENTION:  She was given a higher rating by the VA for the back and knee conditions.  The CI also 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 - 20090203	VARD - 20100915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5239	0%	Spondylolisthesis, Status Post Lumbar Fusion	5237	10%	20100311	
Knee Pain	5099-5014	0%	Patellofemoral Syndrome, Left Knee	5299-5262	10%	20090406	
			Patellofemoral Syndrome, Right Knee	5299-5262	10%	20090406	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI underwent two back surgeries with fusion in March 2007 and June 2007 for spondylolisthesis.  The 18 July 2008 orthopedic examination, 9 months prior to separation, noted the CI had gone back to limited duty.  The range of motion (ROM) study showed flexion of 70 degrees (normal 90), extension of 30 degrees (normal) and right and left rotation of 40 degrees each (normal 30).   

The 24 October 2008 physical therapy (PT) MEB ROM study, 6 months prior to separation, showed flexion of 90 degrees and combined ROM of 240 degrees (normal), after repetitive motion.  There was pain with extension.  The CI had a normal gait and spinal contour and there was no tenderness, spasm or guarding present.  The examiner measured flexion, extension and lateral flexion with an inclinometer instead of the required goniometer specified by the VASRD (§4.71a, Plate V).  Rotation was measured with a goniometer.  

The 8 November 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic back pain, but the CI indicated she was slowly getting better.  She was unable to complete and pass her annual PT test.  The examiner recorded no obvious deformity on the examination.  

At the 6 April 2009 VA Compensation and Pension (C&P) examination, 3 weeks before separation, the CI reported stiffness and numbness from the back condition with constant pain in the lower back and spine that radiated to the mid-and-upper back.  Pain was elicited by activity and stress.  She could function at the time of pain, with medication.  Physical examination showed flexion of 30 degrees (normal 90) and combined ROM of 70 degrees (normal 240).  The examiner noted the joint function of the spine was additionally limited by pain following repetitive use, which additionally limited the joint function, by 10 degrees.  The ROM was not additionally limited by fatigue, weakness, lack of endurance or incoordination following repetitive use.  There was tenderness and the gait was wide based with short steps, but there was no spasm or ankylosis and contour of the spine was normal.  

At the 11 March 2010 C&P evaluation, 11 months after separation, the CI reported stiffness in the low back about 10 days per month, particularly in cold weather and with standing for longer than 1 hour, but no radiating pain.  There had been no incapacitating episodes, she did not require assistive devices and she could bend over.  Physical examination showed flexion of 70 degrees and combined ROM of 175 degrees.  There was no spasm, gait was normal and a straight leg raise test was negative.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5239 (spondylolisthesis or segmental instability).  The VA rated the back condition 10%, coded 5237 (lumbar spine strain), based on the second C&P examination, citing limitation of forward flexion and combined ROM.  The NARSUM examination had no ratable criteria and the first VA examination provided ROM inconsistent with the measurements of the other examinations.  The PT examination was the most complete, consistent with other examinations and proximal to separation.  The panel agreed that a 10% rating based on §4.59, §4.40 and §4.45, was justified for painful motion with functional loss.  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 recommends a disability rating of 10% for the back condition, coded 5239.  

Knee Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5299-5262 and rated 0%.  This 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’s initial charge in this case was therefore directed at determining if 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 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 adjudicated by the PEB.  

According to the STR and MEB NARSUM, the CI’s knee condition began in 2007 without any specific injury or trauma and there was no surgical indication.  Radiographic studies showed normal bilateral knees.  The commander’s statement and other STR evidence did not provide any information that would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.

The PT examination for MEB ROM measurements, 6 months prior to separation, noted a normal gait.  Physical examination showed no tenderness, swelling, effusion, crepitus or signs of meniscal (semi-lunar cartilage) pathology.  The ROM for both the left and right knees was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal).  Painful motion was not recoded.  Measurements were done with a goniometer.  

The MEB NARSUM examination, 5 months prior to separation, noted complaints of not being able to perform her job and, although she was getting better slowly, she was unable to complete and pass her annual PT test.  The examiner recorded there was no deformity on examination, strength was equal bilaterally and there was no edema.  

At the 6 April 2009 C&P evaluation, 3 weeks before separation, the CI reported pain in both knees which occurred constantly.  The pain was localized, aching and sharp.  The ROM study showed left and right knee flexion of 140 degrees and extension of 0 degrees with pain occurring at 120 degrees of flexion.  On examination, there was crepitus and tenderness bilaterally with no signs of edema, effusion, weakness, subluxation, redness, heat, guarding of movement, genu recurvatum or locking pain.  Joint function was additionally limited by 5 degrees due to pain following repetitive use, but was not additionally limited by fatigue, weakness, lack of endurance or incoordination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, analogously coded 5014 (osteomalacia).  The VA rated the left and right knee conditions 10% each knee, analogously coded 5262 (impairment of tibia and fibula), based on the C&P examination, citing mal union of the tibia and fibula with slight knee or ankle disability.  

The panel agreed the PT examination was the most complete, consistent with other examinations and proximal to separation, and showed 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 mal union 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 PT examination.  The panel concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB for either knee.  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 10%, coded 5239 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	5239	10%	
Knee Pain	5099-5014	0%	
	Combined	10%	

The following documentary evidence was considered:

SAF/MRB

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04454.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.