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AF | PDBR | CY2013 | PD-2013-02031

Original file (PD-2013-02031.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2013-02031
BRANCH OF SERVICE: Army BOARD DATE: 20150305

SEPARATION DATE: 20050421

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Automated Logistics Specialist) medically separated for bilateral knee pain and right-sided ilioinguinal pain/dysesthesias. 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 U2L3 profile and referred for a Medical Evaluation Board (MEB). The “bilateral retropatellar pain syndrome” and “ilioinguinal dyskinesia,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “bilateral knee pain secondary to retropatellar pain syndrome” and right-sided ilioinguinal pain/dysesthesias status post multiple surgical procedures as unfitting, rated 10% and 0% respectively, c iting application of the US Army Physical Disability Agency (USAPDA) pain policy for the knee condition. The CI made an initial appeal but withdrew her request and was medically separated.

CI CONTENTION: “My knees are swelling more, and I received a brace for my left knee and looking to acquire a brace for my right knee. My job involves a considerable amount of walking up stairs and hills.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON :

IPEB – Dated 20050121	VA* - (~3 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Bilateral Knee Pain Secondary To Retropatellar Pain Syndrome	10%	5099-5003	Retropatellar Pain Syndrome, Right Knee	5099-5024	0%	20050126
			Retropatellar Pain Syndrome, Left Knee	5099-5024	0%	20050126
Right-Sided Ilioinguinal Pain/Dysesthesias Status Post Multiple Surgical Procedures	0%	8799-8730	Right Ilioinguinal Nerve Entrapment Status Post Multiple Surgeries	8699-8630	10%	20050126
			Painful Scar Status Post Multiple Inguinal Hernia Surgeries	7338-7804	10%	20050126
Other x 0 (Not In Scope)	Other x 3
RATING: 10%	RATING: 30%

* Derived from VA Rating Decision (VA RD ) dated 200 50607 (most proximate to date of separation [ DOS ] ) .

ANALYSIS SUMMARY: The PEB combined the right and left knee pain conditions under a single disability rating, coded analogously to 5003. Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Bilateral Knee Pain Condition. Review of the service treatment record (STR) found an entry in 1998 referencing an injury to the left lower extremity while playing softball. The only subsequent entry was by physical therapy in February 2001 reporting a diagnosis of bilateral retropatellar pain syndrome that was “non-resolving.” On 6 October 2004 (6 months prior to separation), the CI passed an alternate physical fitness test (walking). The narrative summary (NARSUM) on 23 November 2004 (5 months prior to separation) reported a history of bilateral knee pain since 1998. Knee pain worsened during the previous 8 months, and was exacerbated by running, walking, jumping or squatting. Physical exam showed bilateral knee tenderness and no joint instability. Knee X-rays were normal.

At the VA exam on 26 January 2005 (3 months prior to separation), the CI reported that pain was intermittent and associated with exercise or physical activity. Knee pain did not prevent gardening activities, walking, shopping, climbing stairs or pushing a lawn mower. Flare-ups lasted for 2 hours, and the last flare-up was 6 weeks previously. She took pain medication only during flare-ups. Examination showed a normal gait. There was no ligament instability of either knee and repetitive motion caused no additional limitation. X-rays of each knee were normal. The examiner stated there was no pathological evidence to render a clinical diagnosis, and indicated there was no functional impairment resulting from the 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.

Knee ROM (Degrees)	MEB ~5 Mo. Pre-Sep	VA C&P ~3 Mo. Pre-Sep
	Left	Right	Left	Right
Flexion (140 Normal)	140	140	140	140
Extension (0 Normal)	0	0	0	0
Comment	+Tenderenss	+Tenderness
§4.71a Rating	0% or 10%*	0% or 10% *	0%	0%

*Conceding VASRD §4.40 (functional loss) or §4.59 (painful motion)

The Board directed attention to its rating recommendation based on the above evidence. As previously elaborated, the Board must first consider whether each knee remains separately unfitting, having been de-coupled from a combined PEB adjudication. The available STR was silent regarding any knee issue for several years prior to the MEB process. However, the bilateral condition was determined to fail retention standards and was permanently profiled. It is speculative to conclude that the disability confined to a single knee would not have rendered the CI incapable of performing her MOS. There was no indication from the record that one knee was significantly less severe than the other, and clinical examination findings were similar. The VA assigned a 0% rating for each knee, coded analogously to 5024 (tenosynovitis). Board members noted that there was no limitation of motion to justify a compensable rating under the 5260 (limitation of flexion) or 5261 (limitation of extension) codes; and no evidence of instability to warrant a minimum rating under the 5257 code. It was also debated if evidence of functional loss (§4.40) or painful motion (§4.59) was sufficient to justify a 10% rating for each knee. Although knee tenderness was noted on the service exam, painful motion was not reported.

The Board debated the recent successful completion of an alternate aerobic fitness test, tolerance to activities outlined by the VA examiner, and a normal gait. The Board also carefully considered the option of rating both knees together at 10%, the approach taken by the PEB and supported under VASRD §4.71a. Ultimately, the Board concluded that the evidence did not provide sufficient grounds for recommending separate right and left knee disability ratings in this case, and that a rating of 10% coded analogously to 5003 most accurately depicted both the pathology and disability in this case. 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 bilateral knee pain condition.

Ilioinguinal Pain Condition. According to the NARSUM examiner the CI required surgery for recurrent right inguinal hernias in 1999, and in January and June 2002. Evaluation by a pain specialist in September 2004 for ongoing complaints of inguinal pain reportedly rendered a diagnosis of right inguinal dysesthesia. On 6 October 2004 (6 months prior to separation), the CI passed an alternate physical fitness test (walking). The NARSUM physical exam noted multiple surgical scars and tenderness of the right inguinal area. Hip motion also caused pain.

At the VA exam the CI reported that she had been suffering from pain due to nerve damage in the right pelvic area for 6 months. Pain, numbness and tingling were constant, and associated with pain radiating to the medial thigh. Pain was caused by standing, sitting or walking and she needed a cane for support. She could not push a lawn mower because of this condition, but she could climb stairs, vacuum, drive a car, walk, shop and perform gardening activities. Exam showed a normal gait without use of an assistive device. Tenderness was noted of the right lower pelvic region over a surgical scar. The exam did not specify any other tenderness. The examiner’s diagnosis was right ilioinguinal nerve entrapment with an objective factor of painful scar. No neurologic abnormalities were noted.

The Board directed attention to its rating recommendation based on the above evidence. Under an analogous 8730 code (neuralgia of ilioinguinal nerve) the PEB assigned a 0% rating for “moderate” paralysis. The VA’s 10% rating was based on analogous code 8630 (neuritis of ilioinguinal nerve). The VA assigned an additional 10% rating for a painful scar. Board members agreed that the condition was best represented by chronic pain related to the ilioinguinal nerve, and debated if “mild or moderate” or “severe to complete” paralysis most accurately reflected the evidence. In this regard, it was considered that IAW §4.124 (neuralgia, cranial or peripheral) “moderate, incomplete” is the maximum rating allowed. VASRD §4.123 (neuritis, cranial or peripheral) stipulates a maximum rating of “moderate” in the absence of organic changes such as loss of reflexes, muscle atrophy, or sensory disturbances. Since there were no such organic changes documented, the Board agreed that “mild or moderate” was the only applicable descriptor, and therefore a 0% rating was warranted.

The Board also considered that the use of a cane was reportedly required due to this painful condition, yet the CI recently successfully completed an alternate aerobic fitness test. The Board also considered additional rating on the basis of the tender surgical scar, as conferred by the VA. By precedent, the Board does not recommend separation rating for scars unless their presence imposes a direct limitation on fitness. The Board agreed that the preponderance of the evidence in this case does not suggest that the surgical scar was separately unfitting. 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 inguinal 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. As discussed above, PEB reliance on the USAPDA pain policy for rating bilateral knee pain was operant in this case and the condition was adjudicated independently of that policy by this Board. In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the right-sided ilioinguinal pain and dysesthesia condition and IAW VASRD §4.124a, 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 20131030, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD 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, AR20150011181 (PD201302031)

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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AF | PDBR | CY2013 | PD-2013-02031

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