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AF | PDBR | CY2012 | PD2012 01978
Original file (PD2012 01978.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD 12-01978      
BRANCH OF SERVICE: Army  BOARD DATE: 20130822
SEPARATION DATE: 20030805                


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve SPC/E-4 (77F, Fuel Handler) medically separated for neck, low back, bilateral knee, and ankle pain rated as myofascial pain syndrome. The CI developed acute knee and ankle pain during basic training in 1998. She injured her neck under a HUMVEE during Advanced Individual Training (AIT.) While activated in 2003, she injured her neck again as well as her back. These conditions were diagnosed as bilateral retropatellar pain syndrome with subjective ankle pain, neck pain, and acute chronic low back pain. Conservative therapies included physical therapy (PT), muscle relaxants, and pain control; none of which were successful. These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The conditions, characterized as “bilateral retropatellar pain syndrome with subjective ankle pain,” “neck pain,” and “acute chronic low back pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The informal PEB adjudicated the “neck, low back, bilateral knee and ankle pain with subjective symptoms only, x-rays and exam essentially normal, rated (and diagnosed) as myofascial pain syndrome” condition as unfitting, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) , rated 0%. The PEB further noted that it rated the conditions as analogous to myositis without significant loss of joint function, but that she was unable to perform in her MOS. The CI made no appeals, and was medically separated with a 0% disability rating.


CI CONTENTION: “Myofascial pain syndrome/fibromyalgia chronic, back knee and ankle pain, migraines, anxiety disorder, PTSD, depression” [sic]


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 neck, low back, and bilateral knee and ankle conditions are addressed below; no additional conditions are within the 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 Army Board for Correction of Military Records (BCMR).




RATING COMPARISON :

Service IPEB – Dated 20030701
 VA - (7 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Neck, Low Back, Bilat Knee and Ankle Pain – rated as Myofascial Pain Syndrome 5099-5021 0% PFPS, Left Knee 5099-5014 10%** 20020919
PFPS, Right Knee 5099-5014 10%** 20020919
Right Ankle Instability 5271 10%** 20020919
Myofascial Pain Syndrome 5099-5025 NSC** 20020919
Lumbosacral Spine Condition 5237 NSC** 20020919
Left Ankle Pain 5271 NSC** 20020919
Neck Pain 5290 NSC** 20020919
No Additional MEB/PEB Entries
 Migraine Headaches 8100 30%*** Multiple
Other x 11 20020919
Combined: 0%
 *Combined: 30%
* Derived from VA Rating Decision (VA RD ) dated 200 40 512 ( most proximate to date of separation [ DOS ] ).
** CI failed to report for the 20040308 C&P exam so she was denied service connection for a variety of conditions referenced in the chart above. The VA used her 20020919 C&P exam and the corresponding 20021226 Decision Review until she followed up. The rescheduled 20041207 C&P led to increased ratings in the 20050408 VARD. Myofascial Pain Syndrome previously rated as Bilat PFS and Rt Ankle Instability, at 40% effective the day after separation.
***Migraine headaches were added on the 20050408 VARD effective the date of separation at 20% (10% EPTS deduction from the 30%); this was later reversed on the 20111115 DRO review which awarded 30% effective to the date of separation.


ANALYSIS SUMMARY: The 2002 Veterans’ Administration Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine were changed to an interim §4.71a rating standards effective 23 September 2002 which were in effect at the time of her separation. The 2002 standards for rating, which were used by the Service for adjudication, are based on the rater’s interpretation and opinion of range of motion (ROM) impairment regarding degree of severity, whereas the current standards, used by the VA, specify rating thresholds in degrees of ROM impairment measured with an instrument and following a table. The Board utilizes the VASRD in effect at the time of separation. However, seven weeks after her separation, the current VASRD rating standards came into effect on 26 September 2003. These include a table for thoracolumbar range of motion (ROM), and were used by the VA to adjudicate her case.

Board Approach to PEB Consolidated Rating. The Board noted that VA rated the CI for disability both before and after separation and utilized different VASRDs, dependent upon which was in effect at the time. As noted, the Board utilized the VASRD in effect at the time of separation. The Board also noted that the VA re-evaluated her conditions on multiple occasions and increased her ratings based on new findings. However, while DoDI 6040.44 provides for consideration of post-separation VA findings, particularly within 12 months of separation, the Board’s recommendation is premised on the degree of disability at separation. Therefore the highest probative value is assigned to examinations within 12 months from separation.

The PEB combined the neck, low back, bilateral knee, and right ankle conditions as a single unfitting condition coded analogously to myositis, without limited range of motion (ROM) or objective findings, as 5099-5021 and rated 0%. The PEB may have relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes. 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. Not uncommonly, this approach by the PEB reflected its judgment that the constellation of conditions was unfitting and there was neither need for separate fitness adjudications nor was there an implied adjudication that each condition was separately unfitting. If the Board judges that each ‘unbundled’ condition was unfitting in and of itself though, by a preponderance of the evidence, it must then apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a. 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. The history for all conditions is presented on one narrative due to the intertwined nature of the complaints and frequent visits for multiple complaints at one appointment.

The CI enlisted on 10 Sep 1998 and first presented with a one week history of gradual onset bilateral knee pain on 25 September 1998 without a history of trauma documented. When seen four days later, she noted that she had “fractured” both knees. A few days after that, she stated that she had bilateral knee pain and right ankle pain. Her knees would swell and the right lower extremity (RLE) would go numb. It was noted on 13 October 1998 that her bilateral ankle pain was resolving. She was next seen on 3 March 1999 and bilateral knee tendinitis was suspected. She was discharged to the reserves on 11 March 1999. She was seen by a civilian provider after pulling her neck at work (not specified, but presumably in her military job) and noted to have acute torticollis. Over the next few years, she was seen sporadically for both knee and ankle pain. She was awarded VA disability at 10% for right ankle instability effective 28 March 2001. Both knees were service connected, but no disability awarded. Later, the VA raised each knee to 10% for patellofemoral syndrome (PFS) effective 26 July 2002. The left ankle and neck pain were determined to be non-service connected (NSC.) On 28 January 2003, she was involuntarily cross trained into petroleum products for cross leveling. She was then activated on 3 February 2003 in support of Enduring Freedom. During pre-deployment screening, it was noted that she need an updated profile. Her current profile, issued 18 August 2001, was an L2 which limited running to 2.5 miles without other restrictions. She was seen in physical therapy (PT) less than three weeks later for chronic neck and back pain. Shortly after that, the MEB was initiated and an L3 profile for neck and bilateral knee and ankle pain issued. On 20 March 2003, it was noted that she had the above neck, back, knee, and ankle pain. She was noted to have a normal neurological examination including deep tendon reflexes (DTRs), sensory, and motor examinations. On 4 April 2003, she was seen in PT and noted to have a normal gait and free range of motion (ROM) of both upper extremities (BUE) and neck. Her strength was reduced to 4+/5 in BUE, but testing for nerve root irritation was negative. Line of duty (LOD) determinations were made for the knees and ankles as well as neck pain on 7 and 10 April 2003 and for low back pain (LBP) on 21 May 2003.

The narrative summary (NARSUM) was dictated on 9 May 2003, three months prior to separation. The CI reported that she had had back, knee, and ankle pain since Basic Training and neck pain since AIT (advanced infantry training.) On examination, she was noted to guard her knees, but to have normal ROM without signs of instability. She was globally tender over the knees. Her ankles, back, and neck were also normal to examination with normal ROM. The ankles did not show signs of instability. The neurological examination was normal. Provocative testing for nerve root irritation was negative in both the neck and back. There were no VA compensation and pension (CP) examinations proximate to separation. The 10 May 2001 C&P noted a normal examination of the neck and left ankle, bilateral crepitus of the knees, and some laxity of the right ankle with an anterior drawers maneuver. The examination was otherwise normal including the neurological examination and the ROM measurements. A 19 September 2002 C&P, 11 months prior to separation, was by the same examiner. She had a normal gait. The ROM of the right ankle was full, but the laxity remained in anterior drawers testing. The knees were normal other than hamstring tenderness, left > right. X-rays of the knees and right ankle were normal.

The CI was evaluated in neurology on 3 December 2003, four months after separation. Her examination was normal other than inconsistent temperature perception. She was thought to have either early MS (multiple sclerosis) or a functional (non-organic) component to her symptoms. She had several follow-on visits with normal neurological examinations. Electrodiagnostic testing was normal, excluding both nerve root and peripheral nerve dysfunction. Poor effort was noted in all muscles sampled.

The CI was seen in orthopedics on 15 January 2004 and noted to have no foot or ankle issues. A contemporaneous MRI of the spine was reported as normal. On 6 May 2004, the CI complained of occasional popping of the ankle. She was pain free and had a normal examination including x-rays and gait. A request for a handicapped sticker was denied. The examiner wrote “no orthopedic condition present.” The next C&P was on 7 December 2004, 16 months after separation. Her gait was normal. Two tender points were noted in the right rhomboid and paraspinal muscles. The knee examination was unremarkable other than a slightly reduced ROM. The right ankle was reduced in flexion by five degrees, but was otherwise normal. The examination of the neck was normal. The examination of the lumbar spine showed decreased forward flexion to 70 degrees, but was otherwise unremarkable. There was no muscle spasm present. The neurological examination was normal. The examiner determined that myofascial pain syndrome was present.

The Board noted that the PEB bundled the neck, LBP, and bilateral knee and ankle pain as a single unfitting condition and rated it at 0%, coded as 5099-5021, analogous to myositis. The VA initially rated the right ankle at 10%, coded 5271 for instability effective 28 March 2001. The knees were each rated at 0% and the left ankle and neck were NSC. On 26 December 2003, the VA increased the knees to 10% each, noting painful motion, and coded them as 5099-5014, analogous to osteomalacia, for PFS. The neck and left ankle remained NSC. The 12 May 2004 VARD continued these ratings based on service treatment records as the CI did not show for an 8 March 2004 C&P. On 8 April 2005, the VA rated the CI for MPS at 40% using the 7 December 2004 C&P (16 months after separation), subsuming the bilateral knee and right ankle (and probably left ankle) conditions into this diagnosis. The neck and back were NSC.

The Board first considered if separate unfitting conditions existed at the time of separation.

Neck Condition. The CI consistently had normal ROM of her neck with a normal neurological examination. She was noted to have spasm one time in the record, several years prior to reactivation and after an acute injury. She was noted to have degenerative arthritis on x-rays done for the C&P 16 months post separation; the action office opined that this is not an unusual finding in someone approaching 30.

The Board considered if the neck condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting. The well-established principle for fitness determinations is that they are performance-based. The Board could not find any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability. The VA continued to deny service connection for a neck condition, and eventually added her neck pain to an analogous rating of fibromyalgia. It should also be noted that there is insufficient evidence in support of a compensable rating for her neck pain condition, even if were conceded as unfitting. The Board therefore determined that the evidence does not support the addition of the neck as a separately unfitting condition.

Back Condition: The CI was first seen for LBP in PT on 21 February 2003, a little over two weeks after activation. The CI consistently had normal ROM, when documented, with a normal neurological examination. X-rays were noted to be normal on several occasions as was an MRI which is not in evidence. Electrodiagnostic testing was normal despite “poor effort.”

The Board considered if the back condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting. The well-established principle for fitness determinations is that they are performance-based. The Board could not find any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability. Again, it should also be noted that there is insufficient evidence in support of a compensable rating for her back pain condition, even if were conceded as unfitting. The Board therefore determined that the evidence does not support the addition of the back as a separately unfitting condition.

Bilateral Knee Condition. The NARSUM notes the CI complained of acute knee pain since basic training in 1998, and that she was a recipient of VA service connected disability for right and left knee patellofemoral syndrome under VASRD 5099-5014 for 10% each side from 19 September 2002. The Board noted that the VA raised her rating from 0% to 10% during a period when she was not on active duty status. The 10% rating bilaterally was reinstated after she was separated (from her second active duty tour) and was subsequently incorporated into a 40% rating for MFPS made retroactive to the 6 August 2003 by the 8 April 2005 rating decision utilizing post separation examinations and clinical visits. The NARSUM examiner noted she guarded her bilateral knee exam, but had a normal range of motion, with normal deep tendon reflexes at 2/4 and normal 5/5 strength in the lower extremities. The examiner stated she had global tenderness about the bilateral patellae and patellar tendons with a full active range of motion without significant complaints. Bilateral knee x-rays were noted to have well maintained joint spaces and no obvious signs of any fractures or dislocations nor signs of early degenerative changes.

At a VA C&P exam of knees 11 months pre-separation, the examiner noted the CI complained of pain around the posterior medial aspect of both knees, worse on the left than the right. She had minimal anterior symptoms that time. She noted no locking, catching, or giving way and had occasional symptoms of swelling in the knee. Her exam showed a non-antalgic gait, and examination of both knees was symmetrical. She had slightly more tenderness through the distal aspect of the medial hamstrings on the left than the right. There was full active motion with no effusion and no significant tenderness around the patellofemoral articulation was noted. There was no joint line pain. There was no instability. X-rays of both knees showed minimal narrowing right patellofemoral joint space, otherwise no abnormality of the knees.

The Board considered if either knee was separately unfitting. It noted that the CI was service connected by the VA for both knees on 28 March 2001 and that the VA increased the rating to 10% for each knee effective 26 July 2002, over five months prior to re-activation, while she remained on reserve status. The Board noted that the VA maintained this rating after separation, based on the service treatment records, until the knee pain was subsumed under the MPS diagnosis in the 8 April 2005 VARD which was based on an examination 16 moths post-separation. The CI was on an L2 profile which limited running to 2.5 miles at the time she was activated. An L3 profile was issued shortly after activation, but it was for neck, back, knee, and ankle pain rather than a specific condition although bilateral retropatellar pain syndrome, instable knee, and neck spasms were added separately. The NARSUM examiner noted a normal examination, including radiographically, other than non-specific tenderness about both knees. The Board found no documentation in the evidence available for review to support a further deterioration in her knees after activation.

The Board considered if the bilateral knee pain condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above either separately or together. Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting. The well-established principle for fitness determinations is that they are performance-based. The Board could not find any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability attributed to the knees as separate conditions. The Board therefore determined that the evidence does not support the addition of the knees, either separately or combined, as a separately unfitting condition.

Bilateral Ankle Condition. The CI was seen on 1 October 1998, three weeks after accession, for her third visit for knee and ankle pain. She was diagnosed with a possible medial collateral ligament strain, but no comment made on the ankles. Her ankle pain was noted to be resolving on 13 October and no further entries appear in the record for the remainder of this active duty period. She was next seen, at a VA urgent care center, on 6 August 2001 for an acute right ankle sprain which she stated occurred the previous day on reserve duty. No records from a military treatment facility are in evidence though. There are no further entries for her ankles until 8 February 2003, five days after activation, when she was seen for bilateral knee pain and right ankle pain present since basic training. The Board observed that she had received 10% disability for right ankle instability from the VA since 20 May 2001 and that this was sustained on follow-up VARDs both before and after reactivation until the ankle was subsumed under the MPS as discussed above.

At a VA C&P exam of the ankles performed 11 months pre-separation, the examiner noted that since 10 May 2001 the CI had taken anti-inflammatory medications and still used an over-the-counter ankle brace on occasion. The examiner also noted she continued to work as a waitress and hostess, and was a student. The examiner noted she described occasional swelling in the right ankle with occasional symptoms of instability with discomfort over the anterolateral aspect. The VA examiner stated “On examination, she walks with a non-antalgic gait. Examination of the right ankle reveals full active motion. She has some mild tenderness over the anterior lateral aspect. There is no effusion. She has some increased laxity on the right with an anterior drawer and plantar flexion.” X-rays of both ankles showed no bone or joint space abnormality. The NARSUM also noted the CI complained of bilateral ankle pain since basic training in 1998. The examiner noted no gross signs of instability on her ankle exam and she was non-tender to palpation and there was no swelling. At the MEB exam, the CI reported she had been prescribed customized insoles and prosthetic shoes. At the VA Ortho exam performed five months after separation the CI reported an occasional clicking sensation in the right ankle that did not bother her. The examiner reported good ankle and subtalar motion bilaterally with normal gait. X-rays of both ankles were reported by the orthopedic surgeon as unremarkable. The examiner questioned whether she would benefit from custom orthotics or not. At a follow-up orthopedic examination, nine months after separation, the CI requested a handicapped sticker. The examiner stated that the CI did not have an orthopedic condition and that the ankle pain had improved. Her examination, including x-rays, was normal and pain free.

The Board considered if the ankle pain condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above either separately or together. Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting. The well-established principle for fitness determinations is that they are performance-based. The Board could not find any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability attributed to the ankles as separate conditions. The Board therefore determined that the evidence does not support the addition of the ankles, either separately or combined, as a separately unfitting condition.

The Board then considered the appropriate rating for the neck, back, and bilateral knee and ankle conditions as a single unbundled condition. The PEB coded the condition as analogous to myositis, 5099-5021, and rated it at 0%. The VA rated the ankle and knee conditions separately until the 8 April 2005 decision, almost two years after separation. Prior to that decision, the VA had determined the neck, back and left ankle conditions to be NSC. At the 2005 decision, the VA awarded 40% disability coded 5021-5025 (myositis and fibromyalgia), based on the 7 December 2004 C&P, retroactive to separation on 5 August 2003. The Board noted that, while the PEB wrote that the CI had been diagnosed with myofascial pain syndrome, this diagnosis did not appear in the record other than as a statement by the CI to the NARSUM examiner. That examiner, in fact, diagnosed bilateral retropatellar pain syndrome with subjective ankle pain, neck pain, and “acute on chronic low back pain.” The Board considered if the symptom complex fit the diagnosis of MPS better than myositis. It noted that the CI frequently had no symptoms at some examinations and that she did not evidence other findings such as trigger points, fatigue, or disturbed sleep although she did have clicking joints on some examinations and migraine headaches. The Board noted that the sensory examination was inconsistent at times and that one examiner documented poor effort when the electrodiagnostic testing was performed. The Board determined that a diagnosis of MPS could not be supported at separation and that the PEB use of the 5099-5021 analogous code for myositis was not inappropriate. As the CI had normal and painless range of motion in the cited areas of pain at the time of separation, the 0% rating was also appropriate. 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 unfitting neck, low back, bilateral knee and ankle pain 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the unfitting neck, low back, bilateral knee and ankle 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
Myofascial Pain (neck, low back, bilat knee & ankle pain) 5099-5021 0%
COMBINED (w/ BLF)
 0%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20121219, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                  XXXXXXXXXXXXXXXXXXX, DAF
                  President
                  Physical Disability Board of Review



SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB / XXXXXXXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXXXXXX, AR20130021941 (PD201201978)


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)

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