RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   xxxxxxxxxxxxxxxxxx	CASE:  PD-2017-04773
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080402

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “chronic low back pain in a setting of degenerative disc disease” and “retropatellar pain syndrome, left knee,” rated 10% each, with a combined disability rating of 20%. 

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 - 20090210	VARD - 20090203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5237	10%	Degenerative Disc Disease Lumbar Spine	5243	10%	20080825	
Retropatellar Pain Syndrome, Left Knee	5099-5003	10%	Left Knee Suprapatellar Effusion	5014-5261	10%		
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 experienced back pain of unknown etiology for years, but was first evaluated in February 2006.  Lumbar MRI performed in January 2007 showed mild degenerative changes without significant canal or neural foraminal stenosis.  The 30 October 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of constant back pain rated at 7-9/10, which limited his ability to perform aerobic activities, lift objects greater than 20 pounds or wear protective gear.  Physical examination showed tenderness, but no curvature.  The range of motion (ROM) study was incomplete, but recorded flexion to 90 degrees (normal) and side bending to 20 degrees (normal 30) bilaterally.  The 4 December 2007 MEB physical therapy (PT) ROM study showed flexion of 45 degrees and combined ROM of 185 degrees (normal 240).  Measurements were taken with an inclinometer and pain was noted as the limiting factor.  
 
At the 25 August 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported constant, sharp, spasmodic, non-radiating daily back pain that was intensified with laying on his abdomen.  He also stated he could only walk a few yards.  Physical examination showed a stooped posture, waddling gait, guarding and tenderness, but no spasm.  The examiner noted the tenderness and guarding was not severe enough to be responsible for an abnormal gait or abnormal spinal contour.  Thoracolumbar ROM measurements showed flexion of 90 degrees and combined ROM of 240 degrees, after repetition, with pain recorded in all planes.  Lumbar spine X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing mild central and paraspinal tenderness.  The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the C&P examination, citing localized tenderness.  Panel members noted that although the PT flexion measurements closest to separation would have justified a 20% rating for limitation of flexion, the measurements were accomplished using an inclinometer, not the goniometer specified by the VASRD (§4.71a, Plate V).  Therefore, the panel placed higher probative value on the pre-separation NARSUM and post-separation C&P ROM flexion measurements, which were consistent with each other.  The panel agreed that a 10% rating, but no higher, was justified for tenderness as reported on the NARSUM and VA examinations proximate to separation.  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 evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate formula.  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 back condition.  

Left Knee Retropatellar Pain Syndrome.  According to the STR and MEB NARSUM, the CI had experienced left knee pain of unknown etiology for years, but injured it playing basketball in February 2004.  The pre-injury MRI performed in 2003 showed mild patellar tendonitis.  There was no additional testing while in service.  

The MEB NARSUM examination noted CI complaints of constant anterior left knee pain, rated at 3/10, and aggravated by increased activity.  Physical examination showed normal deep tendon reflexes, and strength at 5/5 of all muscle groups except for some weakness with left knee flexion.  The ROM study showed flexion of 135 degrees (normal 140) and extension of 0 degrees (normal).  Tenderness was noted over the patella and medial joint line.  At the MEB PT ROM study, flexion was 120 degrees and extension was normal.  Measurements were taken 3 times using a goniometer and pain was noted as the limiting factor.  

At the C&P examination, 4 months after separation, the CI reported bilateral knee pain with left greater than right giving-way, stiffness and weakness, but he denied episodes of dislocation, subluxation, locking or inflammation.  Physical examination showed a waddling gait and flexion to 140 degrees with extension to 0 degrees, and pain noted in both planes.  The ROM was not additionally limited due to repetition, crepitation, grinding, instability or patellar or meniscus abnormality.  Knee X-rays showed increased fluid on the suprapatellar recess.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, analogously coded 5003 (arthritis, degenerative), citing ROM of 135 degrees and tenderness.  The VA rated the left knee condition 10%, coded 5014-5261 (osteomalacia causing limitation of leg extension), based on the C&P examination, citing painful or limited motion of a major joint.  Panel members agreed there was no limitation of flexion or extension to support ratings under codeS 5260 or 5261.  However, there was evidence of painful motion with functional loss supporting a 10% rating based on VASRD §4.59, §4.40 and §4.45.  Additionally, there was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); history of surgery to remove a meniscus (5259);  or 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 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:

 [AR NUMBER], 

Dear XXXXXXXXXXXX:

	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.

			      

Enclosure