RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04736
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20071030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “low back pain” and “right knee pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “I have many issues with my PTSD.  Night sweats, nightmares, flashbacks any time of the day.  I have knee problems and 2 surgeries on my right knee and one on my left knee.  I also have neck & back, constant stomach problems.  I have depression and difficulties keeping a job due to PTSD.”  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 - 20070830	VARD - 20071221	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Chronic Low Back Pain	5299-5237	10%	20070921	
Chronic Right Knee Pain, Status Post Meniscal Repair	5099-5003	10%	Chondromalacia of Right Knee	5099-5010	10%	20070921	
			Status Post Right Knee Arthroscopic Medial Meniscus Repair 	5259	10%	20070921	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in July 2004 after attempting to catch a falling truck part weighing approximately 60 lbs.  An MRI performed on 13 June 2005 revealed mild degenerative changes and spondylolysis.  
At the primary care clinic (PCC) visit on 8 January 2007, 10 months prior to separation, the examination revealed full range of motion (ROM) with no tenderness or muscle spasm and negative straight leg raise testing.  The spine was normal in appearance and posture and gait were normal.  

The 7 July 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain and numbness in the center of the lower back radiating to both legs.  The back pain averaged 6/10, was constant and was exacerbated with bending, reaching or carrying more than 10 pounds.  Physical examination showed no tenderness or spasm.  He had restricted forward flexion, was unable to perform deep knee bends but had normal heel and toe walk.  

During the physical therapy (PT) ROM study on 16 August 2007, 2 months prior to separation, painful goniometric ROM was recorded as forward flexion to 45 degrees (normal 90) and combined ROM of 160 degrees (normal 240) after repetition.  Waddell signs were absent and there was no weakness or tenderness.  Straight leg raise testing was negative.

At the 21 September 2007 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported chronic lower back pain with stiffness, difficulty bending, tingling in the right leg and numbness in both legs.  The pain occurred 4-5 times per day and lasted for 1-2 hours.  The pain traveled from the back into the right leg.  The pain was aching, sharp and shooting in nature.  The pain level was 3-7/10 and elicited with physical activity, walking, standing and sitting.  He reported one incident of incapacitation for a total of 3 days during the past year.  Physical examination showed no evidence of radiating pain on movement, muscle spasm or tenderness.  Straight leg raise testing was negative and there was no ankylosis of the lumbar spine.  Painful ROM was recorded as flexion to 80 degrees and combined ROM of 230 degrees.  Joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  There was symmetry of spinal motion with normal curvatures of the spine.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  Gross examination of all the other joints and muscles were within normal limits.  The lumbar spine X-ray findings were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded analogously as 5237 (lumbosacral or cervical strain), citing thoracolumbar ROM limited by pain, with guarding present.  The VA also rated the back condition 10%, coded analogously as 5237, based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees.  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 as reported on the VA examination proximate to separation.  There was no muscle spasm 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 evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  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.  

Chronic Right Knee Pain.  According to the STR and the MEB NARSUM, the CI underwent medial meniscal repair surgery in July 2005 and revision on 12 March 2007.  The second surgery did not improve the pain and the CI claimed the pain was worse.  The 7 July 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain, swelling and locking of the knee.  Pain in right knee averaged 4-5 out of 10 with every day movement and was exacerbated by climbing stairs, prolonged standing or prolonged walking.  Physical examination showed a normal gait with no effusion, swelling, tenderness or catching.  ROM was not recorded.  

During the PCC visit on 11 July 2007, 4 months after surgery and 3 month prior to separation, the examiner noted abnormal arthroscopy scars with tenderness observed on movement of the knees.  There was no tenderness, muscle spasm, weakness or swelling and right knee motion was normal without pain.  Post-surgical X-Rays were normal.  

During the PT ROM study on 16 August 2007, 5 months after surgery and 2 month prior to separation, the CI complained of continued knee pain.  On examination, there was painful goniometric ROM with flexion of 120 degrees (normal 140) and extension of 0 degrees (normal).  

At the 21 September 2007 C&P evaluation, 1 month before separation, the CI reported weakness when squatting and could not stand back up.  He had knee stiffness in the mornings and swelling after walking or running.  The knee would give-way occasionally when walking and lacked endurance.  The CI could not walk for more than 30 minutes.  He had occasional locking, popping and cracking when he bent the knee.  He had 5-7/10 right knee pain, but this did not cause incapacitation.  Physical examination showed tenderness and guarding during movement.  There was no edema, effusion, weakness, redness, heat or subluxation.  Examination of the right knee revealed crepitus and very painful squatting.  There was no genu recurvatum (knee hyperextension) or locking pain.  Painful ROM was flexion of 140 degrees and extension of 0 degrees.  The knee was ligamentously stable, but the medial and lateral meniscus tests were abnormal with a slight degree of severity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded analogously as 5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated the right knee condition 10%, coded analogously as 5010 (arthritis, due to trauma), based on the C&P examination, citing painful or limited motion and 10%, coded 5259 (cartilage, semilunar, removal of, symptomatic), citing symptomatic removal of the semilunar cartilage.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The 5259 code was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under that code.  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).  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 right 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 right 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 20170524, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180006728, 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