RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX		CASE: PD-2017-05980 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20051116

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Food Service Operations Specialist, medically separated for “mechanical low back pain [LBP]” and “right knee retropatellar pain syndrome,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION: “…I have had a partial discectomy, permanent numbness in my right foot, calve and skin...”  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 FPEB - 20050915	VARD - 20060602	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical LBP	5237	10%	Lumbar Spine DDD	5010-5243	10%	20060327	
Right Knee Retropatellar Pain Syndrome	5099-5003	0%	Degenerative Changes s/p Right Knee Medial Plica Removal with Shaving and Excision	5259-5020	10%	20060327	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 60%	
	
ANALYSIS SUMMARY:

Mechanical LBP. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in November 2004 after carrying sand bags. A lumbar spine series dated 14 December 2004 showed some narrowing of the disk space at L5-S1.

Conservative treatment consisting of extensive physical therapy (PT) and transcutaneous electrical nerve stimulation (TENS) failed to relieve the pain.  No surgery was recommended.

During the 13 May 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI noted severe LBP. Physical examination showed tenderness with decreased range of motion (ROM). Deep tendon reflexes were symmetric. A 25 May 2005 MEB consultation revealed near-normal ROM for all motions. A PT ROM examination on 26 May 2005, showed gross trunk flexion at 90 degrees (normal) and extension at 10 degrees (normal 30), both limited by pain. At the 31 May 2005 PT examination, ROM for flexion was 80 degrees and combined ROM was 185 degrees (normal 240).

The 16 June 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of lower lumbar pain nearly three quarters of the day with pain intensity rated 3-9/10, which worsened with standing in formation more than 20 minutes, sitting in place for more than 1 hour, or doing heavy lifting over 20 pounds. Physical examination showed tenderness of the paraspinous lumbar muscles. Repetitive ROM was flexion 80 degrees limited by pain with a combined ROM of 185 degrees. Extension and side bending were limited by pain. A right side straight leg raise test (to determine nerve root irritation) was positive while lying down and was negative when sitting up. Left side straight leg raising was negative. An MRI of the lumbar spine showed L4-S1 minimal discogenic disease without central canal stenosis. There were minimal degenerative changes causing neuroforaminal stenosis at L5-S1.

At the 27 March 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported pain in the lower back just to the right of the spine below the waist with pain radiating into the right buttock. An opioid-like medication (tramadol) and a muscle relaxer (Flexeril) were helpful in managing the pain as was the TENS unit which she used about once a day. She used a cane when away from home. Physical examination showed flexion at 60 degrees with repetition without pain; combined ROM was 200 degrees with pain on right lateral flexion and rotation. Tenderness was present. There was no spinal postural abnormality, fixed deformity, or muscle spasm.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the mechanical LBP 10%, coded 5237 (lumbosacral strain), citing no muscular spasm, significant loss or ROM, and tenderness. The VA rated the lumbar spine degenerative disc disease, 20%, dual coded 5010-5243 (arthritis due to trauma-intervertebral disc syndrome [IVDS]), based on the C&P examination, citing ROM.

Panel members noted that the limitation of thoracolumbar flexion reported in the VA C&P examination suggested consideration of the next higher rating of 20%. In assigning probative value to these conflicting examinations, the panel noted the ROM values reported by the VA examiner, 4 months after separation, were worse than those reported by the PT or NARSUM examiners, 5-6 months before separation, and were inconsistent with other observations at the C&P examination (normal contour, slight tenderness, no spasm). There was no record of an injury, accident, surgery, or other development to explain more impairment reflected by the VA ROM measurements. While ROM limitations may have progressed over time, there was no evidence in the record from which to conclude that the severity at separation approached that portrayed by the VA measurements.

The panel also noted that several separate ROM measurements prior to separation warranted a rating of 10% or lower, and agreed that these examinations were more consistent with the STR findings and more reflective of the severity at the time of separation. Therefore, 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 NARSUM and PT 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 mechanical LBP.

Right Knee Retropatellar Pain Syndrome. According to the STR and MEB NARSUM, the CI’s right knee condition began in December 2003 during basic training when her right knee hurt and swelled during running. Treatment was conservative, but the next day, the CI ran with an unstable gait due to the pain and felt a “pop” in her right hip. After 4 months, X-rays showed a right femoral neck stress fracture, and the CI underwent an open reduction, internal fixation of her right hip. In January 2005, an MRI of the right knee showed severe intrasubstance degeneration of the posteromedial meniscus. There were also early degenerative changes of the medial femoral condyle. An orthopedic note dated 28 January 2005 indicated a review of the knee MRI revealed degenerative changes and a complex tear of the posterior horn of the meniscus with contusions to the medial compartment. The right knee pain continued and on 7 March 2005 the CI underwent an arthroscopy, which revealed intact menisci, but an inflamed medial plica (an intra-articular synovial fold), which was removed. A MEB consultation on 28 April 2005 indicated the CI had right knee pain status post (s/p) plica excision. On examination she had a right knee ROM of 0-135 degrees (normal 0-140) and was able to flex and extend with good strength. She had good patellar mobility and a minimal knee effusion. There was no instability of the knee.  The examiner’s diagnosis was retropatellar pain syndrome.

During the 13 May 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, physical examination suggested knee pain was secondary to the back condition. At the 16 June 2005 MEB NARSUM examination, 5 months prior to separation, the CI reported constant burning pain behind her right kneecap with a pain intensity rated at 4/10 that worsened with walking more than 200 yards, climbing stairs, or twisting her knee. A cane was used to ambulate. Physical examination at the orthopedic clinic showed the ROM of the right knee as 0 to 135 with no painful motion reported. Flexion and extension had good strength. Instability testing (Lachman’s, anterior drawer, and posterior drawer signs) was negative. Patellar mobility was good with a minimal knee effusion. Mild joint line tenderness was noted on the medial side and there was superior medial peripatellar tenderness. The examiner’s diagnosis was right knee retropatellar pain syndrome and osteoarthritis s/p removal of a medial plica.

At the 27 March 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported bilateral knee pain. Physical examination showed ROM of 0-130 degrees. There were no symptoms with repetitive motion and no change in ROM. McMurray’s test (to determine a meniscal tear) and tests for instability and laxity were negative. There was no swelling, increased warmth, erythema, or effusion. Minimal crepitus (grinding sensation) and pain were noted with resisted flexion and extension.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the retropatellar pain syndrome 0%, analogously coded 5099-5003 (degenerative arthritis), citing ambulatory restrictions without loss of joint motion. The VA rated the degenerative changes, s/p right knee medial plica removal, with shaving and excision, 10%, dual coded 5259-5010 (cartilage, semilunar, removal of, symptomatic-arthritis, due to trauma), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.
There was 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) code or history of surgery to remove a meniscus (5259) to support a rating under those codes, although an inflamed plica was removed. 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). No additional functional limitation was evidenced by the examinations. 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 mechanical low back condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication. In the matter of the right knee retropatellar pain syndrome 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.

PD-2017-05980 

ARXXXXXXXXXXX, XXXXXXXXXXXXXXXXXXXX 

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.

Sincerely,					      

Enclosure

PD-2017-05980