RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX                                                                      CASE:  PD1301304
BRANCH OF SERVICE: ARMY                                                                           BOARD DATE: 20131217
SEPARATION DATE: 20041026

SUMMARY OF CASE:   Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92Y, Supply Specialist) medically separated for chronic low back and right knee conditions.  The CI had insidious onset of her back and knee pain with no reported mechanism of injury to her back or right knee.  She underwent extensive physical therapy, profiling and chiropractic care with no relief.   Her conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.   She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).     The low back and right knee conditions, characterized as “chronic low back pain” and “right knee pain secondary to retropatellar pain syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB forwarded no other conditions to the PEB.  The Informal PEB adjudicated “chronic mechanical low back pain without history of injury” and “right knee pain without history of injury” as unfitting, rated 10% and 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and the US Army Physical Disability Agency (USAPDA) pain policy respectively. The CI made no appeals and was medically separated.

CI CONTENTION: “Conditions have worsened. Veteran is unable to obtain employment because of conditions and proper care for dependent activities limited.  Lower back pain have worsened unable to provide care for dependents because of conditions.    Right knee conditions have worsened.    Veteran  have  nightmares  because  of  PTSD  incident  in  military  on  rifle  range. Veteran is always afraid of loud noises Veteran has been going to mental health in local city for counseling and medication.”

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 low back and right knee  conditions  are  addressed  below;  and,  no  additional  conditions  are  within  the  DoDI
6040.44 defined purview of the Board.  Posttraumatic stress disorder (PTSD) was not an MEB or PEB condition.   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.     The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate  members  for anticipated future severity  or potential complications of conditions resulting in medical separation.  The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20040825	VA - (5 Mos. Post-Separation)

Chronic Mechanical Low

Condition	Code	Rating	Condition	Code	Rating	Exam
Back Pain	5299-5237	10%	Mechanical Lower Back Pain	5237	*10%	20050401

5260-5014	*10%	20050401

Right Knee Pain	5099-5003	10%	Retropatellar Pain Syndrome, Right Knee
No Additional MEB/PEB Entries	Other x 3	20050401
Combined: 20%	Combined: 20%
Derived from VA Rating Decision (VARD) dated 20050505 (the Original VARD dated 20050106 used only the STR but rated both conditions above at 10% each. Cited VARD used the C&P Exam dated 20050401 per chart above).

ANALYSIS SUMMARY:

Low Back Condition (Chronic Mechanical Low Back Pain).   The CI had non-traumatic onset of lumbar spine pain beginning 3 years prior to the narrative summary (NARSUM).  Her pain was described as constant and without radiation.     There was no associated motor weakness, bowel/bladder or lower extremity complaints.   Treatments including physical therapy, profile restrictions and chiropractic care did not provide relief.  Radiographs and a magnetic resonance imaging  ( MRI)  e x am   of   th e   sp i n e   w e re   n o rm al .  The  r e c o rd   in d i c at e d   t wo emergency department (ED) visits for back pain in July and August 2004 with narcotic pain medication and muscle relaxant prescribed.   The CI was not a surgical candidate.   At the VA Compensation  and  Pension   (C&P)   exam  performed  5   months   after  separation,  the   CI reported  flare-ups  of  back pain  two  times  a  month  which  were  described  as  sharp  and shooting 10/10 pain which was non-radiating.     Repetitive  use,  standing  over  30  minutes, or  walking  more  than  a  mile aggravates the back condition.

The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM (Degrees)	
NARSUM ~4 Mo. Pre-Sep	
VA C&P ~5 Mo. Post-Sep	
Flexion (90 Normal)	

“Full active ROM”	90 (pain at 60)	
Extension (30)		30 (pain at 25)	
R Lat Flexion (30)		30	
L Lat Flexion (30)		30	
R Rotation (30)		-	
L Rotation (30)		-	
Combined (240)		-	

Comment	Tenderness to palpation; normal gait, motor/sensory/reflexes normal	No change after repetitive use; Normal gait, sensory and motor exams.	
§4.71a Rating	10%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  There were no documented residuals and no pathology to support a diagnosis of intervertebral disc syndrome.  The two ED visits might be considered episodes of incapacitation (a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician) related to the low back condition, but were less than a week in duration and would not warrant analogous coding higher than 10%.  The general rating formula for diseases and injuries of the spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.”  The PEB rated the condition for tenderness and the VA rated the condition for painful motion each at 10% under the criteria of code 5237.  There

was  no  evidence of  abnormal spinal  contour, abnormal  gait,  or  limited  ROM  sufficient  to warrant a rating higher than 10% proximate to separation.  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 low back condition.

Right Knee Condition.  The NARSUM notes the right knee pain had an insidious onset.  The pain increased with the use of stairs and standing up from a sitting position.  Pain is located behind the kneecap and has no history of locking or giving way.  The examiner stated “The pain rating is minimal and frequent.”  MRI of the knee was normal.  The MEB physical exam is summarized in the chart below.  At the VA C&P exam performed 5 months after separation, the CI reported knee pain onset in March 2001 with injections into the knee use of Motrin for pain relief and prescription of a knee brace.  The CI no longer uses the brace but continues use of Motrin for pain relief.  The examiner also recorded the following: "Current complaints - She states that she has flare-ups of the right knee about four times a month, lasts about two weeks and has an effect on her work and activities of daily living by slowing her down.  She avoids squatting while lifting. She states that the flare-ups occur after repetitive use of squatting, fast walking or climbing. She describes an intensification of pain from 4/10 to 10/10 with a combination of throbbing and pulling sensation.   She reports stiffness, swelling, a feeling of instability and at times locking. There is no perceived heat or redness.”

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of  additional  ratable  criteria, are  summarized in  the chart below.

Right Knee ROM (Degrees)	Narsum~4 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	
Flexion (140 Normal)	
“Full active ROM”	110	
Extension (0 Normal)		30 (hyperextend)	

Comment	No instability; positive patellar grind and entrapment test	Pain from 90-122 flexion (reduced to 110 w/repetition); no instability	
§4.71a Rating	10%	10%	

The  Board  directs  attention  to  its  rating  recommendation  based  on  the  above  evidence. Although the CI had complaints of instability and locking, there was no objective evidence of instability and an MRI was negative for meniscal damage for possible alternative coding.  The PEB disability description indicated their 10% rating was for “pain, slight and frequent” at 10% and coded at 5099-5003.  This language indicated likely application of the USAPDA pain policy. The PEB’s 10% rating was supported by the USAPDA pain policy, but was compliant with VASRD
§4.71a criteria.   The VA coding of 5260 (leg, limitation of flexion) with 5014 (osteomalacia) would be closer to ideal than the PEB’s analogous coding to 5003 (arthritis, degenerative [hypertrophic or osteoarthritis]); however, both apply the same 5003 criteria and warrant a
10% rating IAW VASRD §4.59 (painful motion) and/or §4.40 (functional loss).  There would be no benefit to the CI for alternate coding and analogous coding under 5003 is acceptable IAW VASRD principles.  There was insufficient evidence in the record to justify a rating higher than
10% for the knee condition.  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 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.  As discussed above, PEB

reliance on the USAPDA pain policy for rating the knee was likely operant in this case and the condition was adjudicated independently of that by the Board.  In the matter of the unfitting low   back  and   right   knee  conditions   and   IAW  VASRD   §4.71a,  the  Board   unanimously recommends no change in the PEB adjudications.   There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Mechanical Low Back Pain	5299-5237	10%	
Right Knee Pain	5099-5003	10%	
	COMBINED	20%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130906, 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, AR20140007238 (PD201301304)
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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
         (Army Review Boards)