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AF | PDBR | CY2013 | PD-2013-01431
Original file (PD-2013-01431.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX     CASE: PD -20 13 - 0 1431
BRANCH OF SERVICE: Army   BOARD DATE: 201 4 0925
Separation Date: 20040 420


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve 2LT/O-2 (13A0O/Field Artillery) medically separated for a back and right knee condition. These conditions 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 P3 profile and referred for a Medical Evaluation Board (MEB). The MEB identified and forward “instability L4-L5 secondary a pars fracture, degenerative disks and spondylolisthesis”, “moderate loss of ROM of his lumbar spine”, “moderate lumbosacral strain” and “arthritis and loss of ROM of his right knee with some quadriceps atrophy” to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated the chronic subjective back pain with L4-5 spondylolisthesis without neurologic abnormality as unfitting and rated it 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The chronic arthritis right knee condition was adjudicated as existed prior to service (EPTS) and not permanently service aggravated, therefore not compensable. The CI made no appeals and was medically separated.


CI CONTENTION : “My original [VA] rating was 10% for my knees and 40% for my back. The back problem was the issue for which I was separated. Approximately 2009-2010 I was re-evaluated and the rating for my back changed from 40% to 0%.”


 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 back condition and the CI’s contended right knee condition shall be 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.

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RATING COMPARISON :
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Service IPEB – Dated 20040225
 VA* - Based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Subjective Back Pain with L4-5 Spondylolisthesis 5239 10% Degenerative Disc Disease (DDD) and Spondylolisthesis 5239-5235 40% STR
Chronic Arthritis Right Knee 5003 ---% Arthritis, Right Knee 5010-5259 10% STR
Other x 0 (Not in Scope)
 Other x 0 (Not in Scope)
Combined: 10%
 Combined: 50%
* Derived from VA Rating Decision (VARD) dated 20040820 (most proxi mate to date of separation )


ANALYSIS SUMMARY : The CI’s contended right knee condition is eligible for the Board review . Although , the Board does not have the authority to recommend a reversal of the EPTS determination; however by precedent the Board does review the fairness of the PEB’s judgmen t that there was not permanent s ervice aggravation. Should the majority of members a gree that there was permanent s ervice aggravation; a disability rating IAW the VASRD, with or withou t a deduction IAW VASRD §4.22 (r ating of disabilities aggravated by active service), will be recommended. Additionally, t he Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; 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. That role and authority is granted by Congres s to the Department of Veterans Affairs, operating under a different set of laws .

Chronic Back Pain with L4-5 Spondylolisthesis Condition . The CI developed consistent back pain while patrolling in a Bradley in February 2003. A lumbar spine magnetic resonance imaging ( MRI ) obtained revealed bilateral L4 spondylolysis wit h g rade 1 spondylisthesis of L4 over L5 a s well as a tiny disc protrusion at L3-4.

During the MEB narrative summary (NARSUM) ( performed approximately 4 months prior to separation ) , the CI’s reported back pain that progressively worse n and that ran down into his legs , stating that pain was greater in his left thigh than the right . The MEB examiner rated the pain, according to the American Medical Association pain scale, as slight and constant. The CI also reported that his pain is controlled by taking non-steroidal anti-inflammatory drug and Vicodin . The CI continued both his c hiropractor and p hysical therapy sessions for spinal manipulation , nonetheless , his back pain was persistent which limited his activities . The examiner opined that the CI was not a surgical candidate and that it was highly unlikely his condition would improve . The MEB NARSUM physical exam ination findings are summarized in the chart below.

The CI was given a p ermanent P3 p rofile for lumbar spine pars fracture with additional restrictions noted. The c ommander’s s tatement indicated that the CI’s back pain had increased si nce August 2003 and that the pain impacts his ability to perform his duties. The physical therapy ROM’s (obtained approximately 2 months prior to separation ) , demonstrated full flexion ROM although with pain and is summarized in below chart .

The CI did not report for his initial VA Compensation and Pension (C&P) exam ination dated 10   August 2004. However, the VA C&P exam performed on 8 August 2008 ( approximately 4 years after separation ) , documents back stiffness and pain that impacts activities performance of a moderate degree with sports and a mild ly degree with exercise. The VA C&P physical exam findings were normal.

There were three ROM evaluations in evidence with documentation of additional ratable criteria which the Board to ok into consideration for recommendation s are summarized in the following chart:

Thoracolumbar ROM (Degrees) Chiropractic 6 Mos. Pre-Sep NARSUM 4.5 Mos. Pre-Sep PT 2 Mos. Pre-Sep
Flexion (90 Normal) 90 30 90
Combined (240) 240 - -
Comment No painful motion, “aching”; Normal strength, reflexes, sensation; Neg. Waddell’s “Bubble” Goniometer used Pos. painful motion
§4.71a Rating 0% 40% 10%
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The Board directs attenti on to its rating recommendation based on the above evidence . The PEB coded the chronic subjective back pain with L4-5 spondylolisthesis without neurologic abnormality condition as 5239 (spondylolisthesis or segmental instability) and rated at 10%. The VA coded the DDD and spondylolisthesis secondary to pars fracture L4-5 condition as 5239 with 5235 (vertebral fracture or dislocation), rated at 40%. The VARD dated 16 October 2008 rated the back condition at 0% based on the VA C&P examination dated 8 August 2008 findings. The General Rating Formula for Diseases and Injuries of the Spine determines that the CI’s symptoms as “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 physical therapy evaluation demonstrated normal flexion and the Board adjudged that this evidence had a higher probative value as it was closer to separation . Additionally, a detailed examination performed by a chiropractor (within 6 months of separation) also collaborate the physical therapy’s ROM evaluation. The ROM measurements documented by the NARSUM exam were adjudged by the Board to represent a short term exacerbation of the CI’s back pain. The Board considered the criteria for a 10% rating “muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour” as both probative exams documented normal thoracolumbar ROM . While the VA exam wa s well outside the Board’s 12 month window, the STRs did contain evidence that the CI experienced back s tiffness that impacted his activity. 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 subjective back pain with L4-5 spondylolisthesis without neurologic abnormality condition.

 Chronic Arthritis Right Knee Condition : The CI had a history of right knee pain while he was a cadet at West Point. Prior to the CI attending the a cademy , he underwent a n arthroscop ic procedure for a right knee osteochondritic dessican’s lesion. An MRI obtained while he was a cadet , showed osteochondritis dessican’s of the lateral aspect of the medial femoral condyle, extensive bone marrow edema and a joint effusion with synovial plicae, however no definitive evidence of cartilage tear. The CI underwent an other arthroscop ic procedure with minimal debridement of the osteochondritis dessican’s lesion, an arthrotomy with proximal tibial bone grafting of the medial femoral condyla r osteochondritis dessican’s lesion and a fixation with three screws. The STR documentation revealed that the CI was seen by a primary c are provider for slight trauma to the right knee , physical exam findings of pain with palpation over the lateral and medial patella and an effusion , otherwise exam was normal. The MEB NARSUM exam ( approximately 4 months prior to separation ), documented that the CI had chronic right knee pain with effusion , with decreased ROM secondary to riding in a Bradley on a more consist basis. There was no instability. A right knee X-ray showed tri-compartmental arthritis. The MEB NARSUM physical exam findings are summarized in the chart below . The CI was not profiled for the right knee. The commander ’ s statement did reference that the CI had chronic right knee problems along with arthritis.

The CI did not report for his initial VA C&P exam which was scheduled on 10 August 2004. A VA C&P exam was completed on 16 January 2008 ( approximately 4 years after separation ), which documented pain with running, inability to squat down , pain after walking on rough terrain , stiffness, swelling, and tenderness. The CI had unde rgone a right partial medial m eniscectomy with chrondroplasty and loose body removal on 22 October 2007. A right knee X -ray images showed mild osteoarthritis if the medial tibial femoral and medial patellofemoral joint compartments. The VA C&P physical exam findings are summarized in the chart below .

The two goniometric ROM evaluations in evidence which the Board took into consideration for recommendations to include documentation of additional ratable criteria are summarized in the chart below.

Right Knee ROM (Degrees) NARSUM 4. 5 Mo s . Pre-Sep VA C&P ~4 Yrs. Post-Sep
Flexion (140 Normal) 100 140
Extension (0 Normal) 0 0
Comment Pos. painful motion; No instability; Pos. quadriceps atrophy Pos. crepitus & “give way” weakness; No instability; Pos. swelling & tenderness
§4.71a Rating 10% (PEB EPTS ) 10 % (VA 10%)
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invalid font number 31502 The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the invalid font number 31502 chronic arthritis right knee condition as 5003 a invalid font number 31502 rthritis, degenerative (hypertrophic or osteoarthritis) however no rating was assigned as the PEB stated the condition invalid font number 31502 was invalid font number 31502 EPTS and was not permanently aggravated by such service. The VA coded the invalid font number 31502 right knee condition invalid font number 31502 as 5010 invalid font number 31502 ( invalid font number 31502 a invalid font number 31502 rthritis, due to trauma invalid font number 31502 ) invalid font number 31502 , substantiated by invalid font number 31502 X invalid font number 31502 -ray findings with 5259 invalid font number 31502 , symptomatic removal of semilunar c invalid font number 31502 artilage invalid font number 31502 and rated at 10% invalid font number 31502 . invalid font number 31502 invalid font number 31502 A later VARD invalid font number 31502 dated invalid font number 31502 8 February 2008 invalid font number 31502 , invalid font number 31502 rated the right knee condition at 100% for invalid font number 31502 post-operative invalid font number 31502 convalescence invalid font number 31502 invalid font number 31502 that was invalid font number 31502 effective invalid font number 31502 from invalid font number 31502 22 October 2007 invalid font number 31502 through invalid font number 31502 1 January 2008 invalid font number 31502 and then invalid font number 31502 decreased invalid font number 31502 the rating to 10% invalid font number 31502 invalid font number 31502 at the invalid font number 31502 expiration of the convalescen invalid font number 31502 t invalid font number 31502 period. The PEB and the VA chose different coding options for the knee condition; however, this did not affect the level of disability rating. invalid font number 31502 The invalid font number 31502 Board did determine that the invalid font number 31502 evidence does support the right knee condition existed prior to invalid font number 31502 service as adjudicated by the invalid font number 31502 PEB. invalid font number 31502 In reviewing the CI’s STR for evidence, the Board found invalid font number 31502 only one visit for “slight knee trauma” invalid font number 31502 ( invalid font number 31502 7 invalid font number 31502 months prior to separation invalid font number 31502 ) and noted t invalid font number 31502 here were no physical profiles invalid font number 31502 for the right knee condition. invalid font number 31502 invalid font number 31502 Based on the evidence present for review, Board invalid font number 31502 consensus invalid font number 31502 invalid font number 31502 was invalid font number 31502 that there was no permanent service aggravation of the CI’s right knee condition invalid font number 31502 and invalid font number 31502 also invalid font number 31502 agreed that the preponderance of evidence did not favor the right knee condition as unfitting. invalid font number 31502 After due deliberation in consideration of the evidence invalid font number 31502 the Board members invalid font number 31502 concluded invalid font number 31502 that there was insufficient cause to recommend a change in the PEB fitness determination for the chronic right knee pain condition. invalid font number 31502


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 chronic subjective back pain with L4-5 s pondylolisthesis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the chronic arthritis right knee condition, 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.

















The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 130916 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record







                          
XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150003926 (PD201301431)


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

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