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AF | PDBR | CY2012 | PD2012 01328
Original file (PD2012 01328.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201328
BRANCH OF SERVICE: Army  BOARD DATE: 20130502
SEPARATION DATE: 20020528


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (63W/Wheeled Vehicle Repairer) medically separated for chronic mechanical low back pain (LBP) and chronic pain right knee and bilateral lower extremity conditions. The CI reported having LBP and right knee pain since November of 2001 with no traumatic event. He was treated conservatively but the condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The chronic back pain and right knee and bilateral lower extremity conditions, characterized as unresolved back pain, right patellofemoral syndrome (PFS) of the knee, and stress fractures of the knee and lower extremity without resolution and were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated the conditions as chronic mechanical low back pain and chronic pain right knee and bilateral lower extremities as unfitting, rated 10% and 0% respectively, referencing the US Army Physical Disability Agency (USAPDA) pain policy for the second condition. The CI made no appeals, and was medically separated.


CI CONTENTION: “I have being diagnosis with degenerative joint disease which I believe is a result of my other injuries”.


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 chronic LBP and chronic right knee and bilateral lower extremity 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 20020425
 VA -based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Mechanical Low Back Pain 5299-5295 10% Lumbar Strain 5295 10% STR
Chronic Pain,Right Knee and Bilateral Lower Extremities 5099-5003 0% Right Patellofemoral Syndrome 5099-5024 10% STR
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 20529 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The PEB combined the right knee and bilateral lower extremities condition as a single unfitting condition, coded analogously to 5003 and rated 0%. The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable Veterans Affairs Schedule for Rating Disabilities (VASRD) sections. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each ‘unbundled’ condition was unfitting in and of itself or at least an indispensable element of a combined effect rating. Thus the Board must maintain 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 Mechanical Low Back Condition. The CI‘s history of LBP began insidiously in November 2001 without trauma history. He was diagnosed with mechanical LBP. Approximately the same time, the CI reported bilateral leg pain. Clinic visit in October 2001 recorded lumbar range-of-motion (ROM) full flexion, and extension limited by 50% with pain. There was pain on palpation in the region of L3-5, motor, and neurological exams were normal. Gait was not recorded. Treatment records are silent going forward until the MEB/narrative summary (NARSUM). The CI was treated conservatively with unsustained improvement. There were no documented report of radicular symptoms, and no evidence of neurological deficits, or spasms in the treatment records. The CI’s profile listed LBP, right PFS of knee with limitation of no running, jumping, marching, squatting, ruck or deep knee bends. The profile allowed walking, swimming, and biking at own pace. On MEB/NARSUM evaluation, 12 April 2002, 6 weeks prior to separation, the CI reported LBP and right knee pain. Physical examination of the lumbar spine recorded full ROM, tenderness to palpation, normal motor strength and no neurological findings. No spasms or gait recorded. The CI was non-attendant for the VA Compensation and Pension (C&P) evaluation.

The Board directs attention to its rating recommendation based on the above evidence. Both the PEB and VA rated the condition at 10% coded 5295 (lumbosacral strain). The VA used service treatment records (STRs) to arrive at their rating decision. In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. Applicable diagnostic codes for rating the back include: 5003 (degenerative arthritis), 5292 (limitation of motion); 5293 (intervertebral disk), and 5295. The higher rating of 20% under 5003 and 5295 codes requires incapacitating episodes that was not supported by the evidence at hand. There was no documented evidence of back spasms that would support a higher rating under either code. The Board considered code 5293 and noted it was not applicable since there was no report or evidence of radiculopathy in the record of evidence. Similarly, the 5292 code is not applicable; ROM was noted to be full at the time of separation. There is no VARSD sanctioned pathway to a rating higher than the minimal compensable rating under any appropriate code. 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 back condition.

Chronic Pain Right Knee and Bilateral Lower Extremity Condition: The CI reported bilateral leg pain without trauma history, in November 2001. Clinic visit 9 January 2002, approximately 4 months prior to separation, recorded normal gait, and full ROM bilateral extremities, normal motor strength bilaterally, and no ligament instability. PFS was diagnosed and anti-inflammatory medication was prescribed for pain. On 30 January 2002, physical therapy note of right knee examination revealed the CI could perform a full squat without symptoms and indicated normal motor strength, and mild pain in patella region. The examiner stated, “patellar symptoms resolving”. Treatment records are silent going forward until the NARSUM. There were no documented report of radicular symptoms, and no evidence of neurological deficits in the treatment records. The CI underwent a bone scan which showed increased uptake over the anterior aspect of both tibias and areas of the feet as well as proximal aspects of the tibias indicating stress fractures. At the NARSUM, 12 April 2002, 6 weeks prior to separation, the CI indicated that most of his pain was in the right knee and thigh. The CI indicated he was unable to run and stated he has had occasional swelling. On physical examination, the examiner recorded full ROM, no evidence of inflammation, no joint line tenderness, and no evidence of knee instability, normal strength and negative neurological tests. The examiner noted patellofemoral tenderness on compression test. The CI was non-attendant for the C&P evaluation.

The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the conditions, rated analogously using the 5003 code at 0% for right knee and bilateral lower extremities. The VA provided rating for PFS, coded analogously 5024 and assigned a 10% evaluation for painful or limited motion of a major joint or group of minor joints. The Board then undertook to unbundled the knee condition and the bilateral lower extremity conditions. All were reviewed by the action officer and considered by the Board. These conditions were judged not to individually fail retention standards. There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. The Board by split vote agreed that the bilateral lower extremity and right knee conditions were not reasonably supported by the record in evidence as individually unfitting, and thus, none were eligible for individual disability rating. The Board unanimously agreed that the unbundling was of no rating benefit to the CI and, thus, recommends no recharacterization.


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 LBP, right knee and bilateral lower extremities conditions was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the right knee/lower extremities pain 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Mechanical Low Back Pain 5299-5295 10%
Right Knee/Bilateral Lower Extremities 5099-5003 0%
COMBINED
 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120724, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130011083 (PD201201328)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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