RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02401
BRANCH OF SERVICE:  Army	BOARD DATE:  20141204
SEPARATION DATE:  20050326

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (88M/Motor Transportation Operator) medically separated for bilateral knee and back conditions.  He was issued a permanent U2/L3 profile and referred for a Medical Evaluation Board (MEB).  Right-sided thoracic and musculoskeletal pain, chronic left knee pain and chronic right knee pain conditions, characterized as not meeting retention standards, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “right knee pain and swelling”, “left knee pain and swelling,” and “myofascial back pain of right posterior thoracic area conditions,” as unfitting, rated at 10%, 10% and 0% respectfully, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeal and was medically separated.

CI CONTENTION:  “The Military give me 20% Disability and the Department of Veterans Affairs give me 50% for my Disability.” 

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 ratings for the unfitting bilateral knees and back conditions are addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20050124 | VA* - (1.5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Right Knee Pain & Swelling | 5259 | 10% | Residual, Medial Meniscal Repair, Right Knee | 5261 | 10% | 20050511
Left Knee Pain & Swelling | 5259 | 10% | Residual, S/P Arthroscopy, Left Knee w/ Limitation Flexion | 5015-5260 | 20% | 20050511
| | | Residual, S/P Arthroscopy, Left Knee w/ Limitation Extension | 5261 | 10% | 20050511
Myofascial Back Pain of right posterior thoracic area | 5099-5021 | 0% | No VA Entry for thoracic myofascial pain
Lumbar spine condition not referred by MEB | Mild Hypertrophic Changes, Lumbar Spine | 5003-5242 | 10% | 20050511
Other x 0 (Not in Scope) | Other x 3 | 20050511
Combined:  20% | Combined:  50%
Derived from VA Rating Decision (VARD) dated 20051118 (original VARD 20050908 deferred left knee condition)
No change to ratings derived from subsequent C&P exam

ANALYSIS SUMMARY:

Right Knee Pain and Swelling.  According to service treatment records (STRs) and the MEB narrative summary (NARSUM), the CI underwent right knee arthroscopic surgery with medial meniscectomy to remove a torn medial meniscus in May 2001.  A permanent physical profile designated as L2 issued on 11 June 2002 limited the CI’s running to two miles, at his own pace and distance.  Army physical fitness test records show the CI passed the fitness tests in May 2002, December 2002, March 2003 and May 2003 including the two mile run (time of 16:58).  The STRs are silent with regard to right knee pain until 9 February 2004 (3 months after left knee surgery), when the CI reported bilateral knee pain to his orthopedic surgeon.  No new injury to the right knee was recorded and examination was indicated to show normal range-of-motion (ROM) without instability. 

At the time of the MEB NARSUM examination on 6 October 2004, chronic right knee pain was recorded with popping and clicking and effusions limiting his activity.  On examination, the right knee flexed 120 degrees and extended to 0 degrees.  There was report of pain at the extreme of flexion.  The McMurray test (for meniscus problems) was reported to cause pain.  There was no effusion and no instability.  

At the VA Compensation and Pension (C&P) examination on 11 May 2005 (approximately 6 weeks after separation), the CI reported right knee pain aggravated by activity and walking.  On examination the right knee flexed to 140 degrees and extended to 0 degrees “without pain or difficulty.”  There was no swelling or effusion.  Ligaments were intact and there was no instability.  The McMurray test (for meniscus symptoms) was negative.  A VA clinic treatment record the same day noted both knees to have good ROM with good stability and without tenderness or effusion.  A 29 July 2005 VA clinic treatment record noted a normal gait.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition at 10% coded 5259 (symptomatic status post removal of meniscus), noting full motion and good stability.  The VA rated the right knee at 10%, code 5261 (limitation of extension) noting no limitation of motion but citing reported pain with use.  The Board noted the examinations did not show any limitation of motion that supported a minimum rating under the respective VASRD diagnostic codes 5260 (limitation of flexion) or 5261 (limitation of extension).  All members agreed the symptomatic post removal of meniscus code which provides for a maximum rating of 10% best described the impairment.  A 10% rating would also be supported with consideration of §4.40 (functional loss), when rating analogously under the limitation of motion codes but provides no benefit to the CI.  There was no instability to support a separate rating under diagnostic code 5257 (recurrent subluxation or lateral instability).  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 right knee pain condition.

Left Knee Pain and Swelling.  According to STRs and the MEB NARSUM, the CI underwent left knee arthroscopic surgery with medial meniscectomy to remove a torn medial meniscus on 28 October 2003.  A magnetic resonance imaging (MRI) and arthroscopic findings did not indicate a lateral meniscus injury.  Approximately 2 months after surgery, a physical therapy examination on 15 January 2004, noted active flexion to 115 degrees and active extension to 0 degrees with pain when performing squats.  Left quadriceps strength was noted as good.  Orthopedic examination performed on 9 February 2004 (3 months after left knee surgery), noted persisting left knee pain.  Examination indicated normal ROM without instability.  X-rays of the left knee obtained on the same day demonstrated “mild osteoarthritis”.  At the time of the MEB NARSUM examination performed on 6 October 2004, chronic left knee pain was recorded associated with mechanical symptoms and effusions limiting his activity.  On examination, the left knee flexed 130 degrees and extended to 0 degrees without report of pain with motion.  The McMurray test (for meniscus problems) was reported to cause pain.  There was no effusion and no instability.  At the VA C&P examination on 11 May 2005 (approximately 6 weeks after separation), the CI reported left knee pain aggravated by activity and reported giving away symptoms, and easy fatigability.  On examination there was an antalgic gait.  The left knee examination noted that there was no swelling or effusion and that the ligaments were intact without instability.  The McMurray test (for meniscus symptoms) was negative.  Regarding the ROM examination the examiner recorded there was pain with passive movement to 0 degrees but that there was “full flexion and extension as previously mentioned.”  A VA clinic treatment note recorded the same day documented both knees to have good ROM with good stability and without tenderness or effusion.  A 29 July 2005 VA clinic treatment record entry noted a normal gait.  The VARD dated 8 September 2005 deferred its rating decision for the left knee and requested additional examination information regarding limitation of motion after repetition.  The C&P examination addendum dated 3 November 2005 reported the left knee flexed from 0 degrees to 70 degrees “with pain starting at 40 degrees and going through to 70 degrees. Extension was a minus 10 degrees.”  The McMurray test was stated as positive for both the medial meniscus and the lateral meniscus.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10% coded 5259, symptomatic status post removal of meniscus, noting full motion and good stability.  The VA granted a separate 20% rating for limitation of flexion coded analogous as 5015-5260 (new growths of bone, benign/limitation of flexion) citing the November 2005 addendum reporting flexion of 70 degrees with painful flexion from 40 to 70 degrees.  The Board noted there was no benign new growth of bone as coded by the VA.  The 20% rating under VASRD code 5260 (limitation of flexion) for flexion limited to 30 degrees.  Even considering the point at which pain began, 40 degrees, the 20% rating is not supported under this code.  The flexion of 70 degrees does not support a minimum rating under code 5260, however the painful motion would support a 10% rating with application of §4.59 (painful motion).  The VA also granted a separate 10% rating for code 5261 (limitation of extension) citing 10 degrees loss of extension based on the November 2005 C&P addendum.  

However the C&P addendum indicated the knee demonstrated motion from 0 degrees (full extension) to 70 degrees (flexion).  The “minus 10 degrees” was in the context of reporting onset of painful motion.  The Board considered the November 2005 C&P examination addendum but noted it was inconsistent with all other examinations in the STRs, the MEB NARSUM, the initial VA C&P examination in May 2005 and VA treatment records proximate to separation demonstrating good ROM and a normal gait.  The November 2005 VA C&P addendum examination also reported a positive McMurray test for the lateral meniscus however, MRI and arthroscopic findings did not indicate any injury or pathology of the lateral meniscus.  The Board therefore put greater probative weight on the MEB NARSUM examination in making its rating recommendation.  There was not limitation of motion that supported a minimum rating under the respective VASRD diagnostic codes 5260 (limitation of flexion) or 5261 (limitation of extension).  All members agreed the symptomatic post removal of meniscus code 5259 which provides for a maximum rating of 10% best described the impairment.  A 10% rating would also be supported with consideration of functional loss (§4.40) when rating analogously under the limitation of motion codes but provides no benefit to the CI.  There was no objective evidence of ligamentous instability to support a separate rating under diagnostic code 5257 (recurrent subluxation or lateral instability).  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 left knee pain condition.

Myofascial Back Pain of Right Posterior Thoracic Area.  The CI sought care on 2 March 2004 for right periscapular (shoulder blade region) muscle strain incurred while performing push-ups and sit-ups.  Follow-up examination in the clinic on 4 March 2004, noted point tenderness of para-vertebral muscles at the mid thoracic level adjacent to the shoulder blade (T-5).  There was no spinal tenderness.  X-rays of the thoracic spine performed on 4 March 2004 were normal.  A physical U2 profile on 19 March 2004, noted upper back pain, indicating no overhead lifting but no restrictions for performing physical training (PT) test push-ups or sit-ups.  No further encounters for care of upper back pain are present in the STR.  On 20 April 2004 the CI passed his PFT test completing 75 push-ups and 53 sit-ups.  At the time of the MEB history and physical examination in July 2004, the CI reported upper back pain on the DD Form 2807, Medical Examination.  The examiner noted a history of right sided upper back pain for 5 months that was aggravated by sit-ups.  The MEB NARSUM recorded CI reported right periscapular posterior chest wall pain aggravated by activity and resolved with rest.  The CI reported he was unable to perform sit-ups.  ROM examination of just the thoracic spine (without the lumbar spine) was normal (60 degrees flexion, 10 degrees extension, 45 degrees rotation and 40 degrees lateral bending).  There was tenderness of the paraspinal muscles at the level of the scapula.  Strength of the extremities was normal.  

At the VA C&P examination performed on 11 May 2005, the CI reported chronic thoracic and lumbar pain since 2001 without any preceding history of trauma or injury.  He reported the pain never goes away and is aggravated by activity such as excessive walking or car washing.  On examination, the spinal curvatures were normal.  There was no spasm or tenderness and the CI was able to touch his toes.  Extremity strength and reflexes were normal.  Thoracolumbar ROM was reported with flexion of 90 degree, extension 25 degrees, lateral bending 30 degrees to both sides, and rotation 30 degrees to both sides.  X-rays of the lumbar spine were performed (showing some degenerative changes of the lumbar spine).  On the same day 11 May 2005, a VA clinic treatment record noted report of chronic lower back pain but not upper back pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right posterior thoracic myofascial pain 0% (coded 5099-5021; analogously to myositis) citing normal imaging and no loss of motion.  The VA granted a 10% rating for the lumbar spine citing mild hypertrophic changes on X-ray.  STRs and MEB examinations are silent with regard to a low back (lumbar) condition interfering with performance of duties.  There was no limitation of thoracic spine motion that supported a minimum rating.  In addition, there was not a thoracic spine injury and X-rays were normal of the thoracic spine.  At the C&P examination the CI reported onset of the condition in 2001 however there are no STR entries documenting complaint of right posterior thoracic pain until March 2004.  The CI strained the muscles between the thoracic spine and the right scapula in March 2004.  Approximately 7 weeks after the initial periscapular muscle strain, the CI passed the physical fitness test performing 75 push-ups and 53 sit-ups.  The commander’s statement makes no references to limitations due to the upper back myofascial pain.  At the time of the May 2005 VA C&P examination, there was no abnormality of the thoracic and scapular region on examination.  The VA granted a 10% rating for the lumbar spine not the thoracic spine.  Although the CI reported subjective pain and limitation of function, the Board did not conclude there was sufficient evidence of functional impairment of the myofascial pain of the right upper back region to support a minimum rating.  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 myofascial back pain of right posterior thoracic area condition.

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.  In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the myofascial back pain of right posterior thoracic area condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131107, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-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 XXXXXXXXXXXXXXXXX, AR20150007055 (PD201302401)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02401