RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05031
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E7, Motor Transport Operator, medically separated for “chronic low back pain (LBP)” and “right knee pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  Review of all conditions requested.  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 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 - 20060321	VARD - 20060911	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5299-5242	10%	Lumbar Spondylosis	5299-5239	10%	20060314	
Right Knee Pain	5099-5003	10%	Mild Degenerative Changes, Right Knee	5259-5010	10%	20060314	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic LBP.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 2003 after a vehicle accident while deployed.  An MRI showed a disc protrusion at L5-S1 and bulging discs at L3-4 and L4-5.  The 14 December 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of 7/10 back pain aggravated with bending.  Physical examination showed tenderness and an antalgic gait, but no evidence of spasm or guarding.  The range of motion (ROM) study was completed on 1 December 2005 and showed forward flexion of 80 degrees (normal 90) and combined ROM of 210 (normal 240).  There was no indication of painful motion.  

During the 14 March 2006 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported 7/10 LBP radiating to the right lower extremity elicited by physical activity and stress.  The CI reported painful motion and weakness of the implanted joint.  Over the past year the CI had three incidents of incapacitation for a total of 6 days.  Physical examination showed normal posture, but an abnormal gait for which he used a cane and a right knee brace.  There was tenderness, but no spasm or ankylosis.  The ROM evaluation, after repetition, showed flexion of 75 degrees and combined ROM of 185 degrees.  ROM limitations were due to pain, fatigue, weakness, and lack of endurance in all planes of motion.  There was no signs of intervertebral disc syndrome (IVDS) with chronic and permanent nerve root involvement.  Lower extremity motor strength, reflexes, and sensation were normal, and straight leg raise testing was negative.  

At the 15 May 2007 VA C&P examination, 12 months after separation, the CI reported 7-8/10 LBP radiating to the right lower extremity.  Physical examination showed no assistive devices for ambulation and normal spinal alignment.  Lower extremity reflexes, sensation, and muscle strength were normal with the exception of mild loss of right hamstring strength (4/5).  The ROM evaluation, after repetition, showed 60 degrees of flexion and 150 degrees of combined ROM.  There was pain with passive motion at the end ranges in all planes of motion based on muscle guarding.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing positive tenderness and ROM greater than 235 degrees.  The VA also rated the back condition 10%, analogously coded 5299-5239 (spondylolisthesis), based on the C&P examination, citing “forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.”  

Panel members 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 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 documentation of IVDS 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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Right Knee Pain.  According to the STR and MEB NARSUM, the CI underwent right knee medial meniscal tear debridement in July 2004 and right meniscal transplant in August 2005.  The MEB NARSUM examination noted complaints of 7/10 right knee pain aggravated with stairs, walking, prolonged standing, and bending.  Physical examination showed an antalgic gait, use of a right knee brace, and an inability to heel and toe walk.  There was no swelling, warmth, redness, ligamentous instability or crepitus, but there was tenderness to the medial aspect of the right knee.  The ROM study was completed on 1 December 2005 and showed flexion of 128 degrees (normal 140) and extension of 0 degrees (normal).  

During the 14 March 2006 VA C&P examination the CI reported 7/10 constant right knee pain elicited by physical activity.  The condition does not cause incapacitation and at the time of pain he could function with medication.  The CI reported losing time from work times per week.  Physical examination showed an abnormal gait due to a limp, use of a cane for balance, and a right knee brace for ambulation due to instability.  There were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement.  The right knee ROM study, after repetition, showed 120 degrees of flexion and 0 degrees of extension.  Provocative clinical testing of the anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the medial and lateral meniscus, to elicit ligamentous instability, was positive for slight instability.  

The 3 January 2007 MRI, 7 months post-separation, showed effusion, a Baker’s cyst, edema in the medial femoral condyle, and a highly abnormal transplanted medial meniscus believed to be torn both posterior and anterior.  At the VA C&P examination 12 months after separation, the CI reported 5/10 right knee pain with flares to 8/10.  He complained of right knee weakness, stiffness, give-way and occasional swelling due to prolonged standing and walking.  Physical examination showed no assistive devices for ambulation, but there was mild loss of right hamstring strength (4/5).  He was unable to squat due to back and knee pain.  On examination, there was tenderness along the medial joint line, slight swelling, patellar crepitus, but no detectable effusions.  The ROM evaluation, after repetition, showed 90 degrees of flexion, with pain, and 0 degrees of extension.  Provocative clinical testing to elicit ligamentous instability or meniscal pathology was negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing moderate and frequent pain IAW the US Army Physical Disability Agency pain policy.  The VA also rated the right knee condition 10%, dual coded 5259-5010 (removal of semilunar cartilage due to traumatic arthritis), based on the C&P examination, 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).  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.  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 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).  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 right knee condition.  

BOARD FINDINGS:  In the matter of the chronic low back pain and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the chronic right knee pain and IAW VASRD §4.71, 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.  

XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX:

	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.