RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD1201689	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20131030
Date of Permanent SEPARATION:  20051207	

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (25L20/Cable System Installer/Maintainer) medically separated for chronic non-radiating low back pain and chronic bilateral knee pain.  His back pain began in 2002 during a deployment to Kosovo and his bilateral knee pain began in 1996 when he fell 30 feet while climbing a telephone pole.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The back and bilateral knee conditions, characterized as “chronic non-radicular low back pain” and “chronic bilateral knee pain” were forwarded as not meeting retention standards, to the Physical Evaluation Board (PEB) IAW AR 40-501.  A symptomatic pes planus condition was identified by the MEB and also forwarded as failing retention standards.  The informal PEB adjudicated the chronic low back and bilateral knee pain conditions as unfitting, rated 10% and 0%.  The remaining condition was determined to be not unfitting and therefore not ratable.  The CI made no appeals, and was medically separated. 

CI CONTENTION:  The CI elaborated no specific contention in his application.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The Service ratings for the unfitting low back and bilateral knee conditions are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:  
   
Service IPEB – Dated 20051026 | VA - (4 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Non-Radiating Low Back Pain | 5237 | 10% | Residuals of Lumbar Spine Strain w/ Osteophyte Formation | 5010-5237 | 10%* | 20050721
Chronic Bilateral Knee Pain | 5099-5003 | 0% | Residuals Anterior Cruciate Ligament Tear, Post-Op Lt Knee | 5299-5260 | 10% | 20050721
| | | Rt Ankle Osteoarthritis | 5010-5271 | 10% | 20050721
| | | Residuals Rt Knee Strain | 5299-5260 | 0% | 20050721
No Additional MEB/PEB Entries | Other x 4 | 20050721
Combined:  10% | Combined:  40%
Derived from VA Rating Decision (VARD) dated 20051219 (most proximate to date of separation [DOS]).   
* Rating was raised to 20% in a 20081028 VARD effective 20071217. 

ANALYSIS SUMMARY:  The PEB combined the chronic bilateral knee pain conditions as a single unfitting condition rated for pain as 5099-5003 at 0%.  The PEB may have relied on the USAPDA pain policy for not supplying separately compensable VASRD codes.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.  

Chronic Non-Radiating Low Back Condition.  The narrative summary (NARSUM) notes the CI had a history of localized low back pain (LBP) following an injury in 2002.  Initial lumbar spine x-rays were normal and the CI improved with medications but experienced worsening LBP after running.  MRI 22 July 2004 was normal and repeat lumbar x-ray 17 May 2005 showed mild arthritic changes of the lower back.  The orthopedic diagnosis was lumbago and the CI was treated conservatively again with some improvement, but LBP continued.  At the MEB exam 27 September 2005, approximately two months prior to separation, the CI reported left sided LBP without radiation that contributed to his inability to perform his full duties.  The MEB physical exam noted limited lumbar range of motion (ROM) of flexion 60° (normal 90°) and extension of 20° (normal 30°) with pain at end range of motion.  There was no muscle spasm noted.  Strength, sensation and reflexes of the bilateral lower extremities were normal.  At the VA Compensation and Pension (C&P) exam 21 July 2005, approximately four months before separation, the CI reported back pain since the fall in 2002.  The VA exam showed mildly reduced lumbar flexion of 85° but otherwise normal ROM with mild pain and stiffness with motion.  The exam noted normal spinal curvature and negative straight leg raise tests.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated a permanent disability rating of 10% for the chronic LBP condition coded as 5237 (lumbosacral strain).  The VA rated the LBP condition as 5010-5237 (lumbosacral strain with osteophytes) also at 10%.  The Board deliberated the rating of the CI’s LBP condition.  The record supports that CI had chronic LBP without radicular symptoms, without muscle spasm on exam, with reduced lumbar ROM at the MEB exam of 60° and at the VA C&P exam of 85°.  There is no evidence in the record of a separately ratable peripheral neuropathy or documentation of incapacitating episodes due to the LBP.  The Board agreed that the CI’s disability due to the LBP condition met the 10% rating coded as 5237.  The Board found there was no path to a higher rating coding under 5243 IAW the VASRD Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

Chronic Bilateral Knee Condition.  The NARSUM notes the CI had a history of chronic knee pain in both knees since 1996 following a fall.  X-rays of both knees in 2005 were normal.  An MRI of the left knee in May 2005 was consistent with injury of the anterior cruciate ligament (ACL) ligament and a bone bruise.  The CI had arthroscopic repair of a left knee ACL tear on 4 August 2005.  Post-operative x-rays of the left knee showed changes consistent with ACL repair.  At the MEB exam 27 September 2005, approximately two months before separation, the CI reported bilateral knee pain aggravated by stairs or climbing activities.  Exam of the right knee showed full range of motion, without instability or patellar apprehension and a negative patellar grind test, with some catching of the patella on flexion and extension.  Exam of the left knee, approximately two months post arthroscopic surgery, showed mild swelling with ROM of 0°-110° (normal 140°).  There was a negative anterior drawer test and the knee was noted to be otherwise stable.  At the VA C&P exam 21 July 2005, approximately four months before separation, the CI reported bilateral knee pain following injury in 1996.  The CI’s right knee pain responded well to conservative treatment.  The CI was scheduled for surgery for left ACL repair at the time of the VA exam.  At the VA exam the CI had a non-antalgic gait and walked without difficulty or a supportive device.  ROM of the left knee was flexion of 125°and extension of 5° (normal 0°), with pain and stiffness.  There was no evidence of laxity, instability, or meniscal injury.  There was mild tenderness to palpation of the patellofemoral area, without swelling.  ROM of the right knee was full, without any abnormalities noted on exam.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral knee pain as one unfitting condition coded as 5099-5003 (analogous to arthritis) at 0%, noting a pain rating of slight, occasional.  The VA rated the left knee as 5299-5260 (analogous to limitation of leg flexion) at 10% and the right knee also as 5299-5260 at 0%.  The Board first undertook to unbundle the left and right knee pain conditions.  The permanent profile and the Commander’s statement both noted bilateral knee pain.  The Board agreed that there was evidence in the record to support that both the left and right knees were reasonably considered separately unfitting.  The Board next considered the rating of the CI’s chronic left knee pain condition.  MRI of the left knee 17 May 2005 showed an ACL tear.  The CI had arthroscopic surgery for repair of the left knee ACL tear 4 August 2005, approximately four months prior to separation.  Both the MEB and VA examinations noted mildly decreased painful left knee ROM without laxity or instability.  The MEB exam, which occurred approximately two months after surgery, noted mild swelling of the left knee.  The examiner opined that the CI had progressed well post-operatively and that it was anticipated he would have a full recovery, but noted that the knee pain was expected to be chronic.  The Board opined that the CI’s disability due to the left knee condition met the 10% rating for painful motion coded as 5260 and there was no path to a higher evaluation coding under 5257 (knee impairment) due to instability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), and IAW VASRD 4.59 (painful motion) the Board recommends a disability rating of 10% for the unfitting left knee pain condition coded as 5260 (limitation of leg flexion).  The Board next deliberated the rating of the CI’s chronic right knee pain condition.  Notes in the STR show that the last visit for right knee pain was 16 months prior to separation and the right knee exam was normal at that time, with the CI noting a pain level of 2 out of 10.  Right knee x-rays 18 May 2005 were normal and both the MEB and VA examinations of the right knee were normal without mention of painful motion.  The Board agreed that the CI’s disability due to the right knee pain condition did not meet the criteria under 5260 for a compensable rating and there was no path to a higher evaluation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the unfitting right knee pain condition coded as 5260 (limitation of leg flexion). 

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic bilateral knee pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic bilateral knee pain condition, the Board unanimously recommends a disability rating as follows: an unfitting chronic left knee pain condition of 10%, coded 5260 IAW VASRD §4.71a and an unfitting chronic right knee pain condition of 10%, coded 5260 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

UNFITTING CONDITION | VASRD CODE | RATING
Chronic Non-Radiating Low Back Pain | 5237 | 10%
Chronic Left Knee Pain | 5260 | 10%
Chronic Right Knee Pain | 5260 | 0%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120921, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
	           			   XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SFMR-RB							
MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20140002215 (PD201201689)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

PD1201689