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AF | PDBR | CY2014 | PD-2014-02189
Original file (PD-2014-02189.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-02189
BRANCH OF SERVICE: Army  BOARD DATE: 20150326
SEPARATION DATE: 20060511


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Pneudraulics Rep) medically separated for chronic neck pain and bilateral knee pain. The 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 L2 profile and referred for a Medical Evaluation Board (MEB). The chronic neck pain condition, characterized as “Chronic neck pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded “bilateral anterior knee pain syndrome; history of sinusitis and unilateral loss of smell history of sleep disorder” condition for PEB adjudication. The PEB adjudicated “chronic neck pain” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD), and “chronic bilateral anterior knee pain” rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “Would have continued in the service if I didn't have these disabilities. Have had loss [sic] of jobs, difficulty maintaining employment, job-related injuries as a result of the disabilities. Decreased quality of life due to chronic pain, have to take 6 different pain and mental health related medications. Also have nightmares and suicidality as a result of the physical and emotional stress associated with the 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 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 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 :

Service IPEB – Dated 20060322
 VA – (2.5 Yrs. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam

Chronic Bilateral Knee Pain
 5099-5003
0%

 Right Knee Patellofemoral Pain Syndrome 5099-5024 10% 20081022
Left Knee Patellofemoral Pain
Syndrome		 5099-5024 10% 20081022
Chronic Neck Pain
 5237 10% Cervical Spine Degenerative Disk Disease 5243 10% 20081022
Left Arm Radiculitis 8515 10% 20081022
Other x 2 (Not in Scope)
 Other x 2 (Not in Scope)
Combined: 10%
 Combined: 40%
Derived from VA Rating Decision (VARD) dated 20091103 ( most proximate to date of separation [DOS]). “40% from 20080311 (Bilateral factor of 1.9 percent for diagnostic codes 5024 , 5024 .”

ANALYSIS SUMMARY: The PEB combined the left and right knee pain conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis). 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.

Chronic Bilateral Knee Pain Condition. Review of the service treatment record (STR) revealed a diagnosis of bilateral patellofemoral pain syndrome in 2003, and a request for specialty referral for bilateral knee pain in November 2004. Imaging studies showed no evidence of arthritis or of ligament or cartilage damage.

At the MEB exam on 30 November 2005 (5 months prior to separation) the CI reported right knee swelling with exercise, and that both knees “collapse out from under me” once or twice per week when walking, running, getting out of a car, or climbing stairs. The MEB physical exam noted bilateral knee tenderness, right worse than left.

The narrative summary (NARSUM) evaluation on 2 December 2005 (5 months prior to separation) noted an inability to perform knee bending exercises or any running. A complaint of “instability symptoms” was also recorded. Physical exam revealed a normal gait. Knee flexion was 125 degrees bilaterally (normal to 140 degrees). Right knee extension was minus 10 degrees (normal 0 degrees) and left knee extension 10 degrees. Ligament and meniscal testing was normal bilaterally. Knee crepitus was absent, but painful motion and tenderness was not mentioned. The commander’s statement on 5 December 2005 reported that the CI suffered from bilateral knee pain since approximately 2001.

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 PEB’s DA Form 199 reflected application of the VASRD analogous 5003 code for rating the right and left knee pain conditions together at 0%. The Board agreed it would be overly speculative to conclude that either knee was not unfitting. Clinical notes reflected difficulties with both knees and a bilateral condition was profiled. The VA’s 10% rating for each knee under an analogous 5024 code (tenosynovitis) was based on an examination 2.5 years after separation, which held no probative value in the Board’s deliberations. The Board considered separate ratings of 10% for each knee. The NARSUM examiner reported the right knee lacked 10 degrees of full extension, which would warrant a 10% rating under the 5261 code (leg, limitation of extension of). However, it was concluded that this degree of limited extension was inconsistent with a normal gait. Although mild limitation of flexion was present, the degree of limitation was non-compensable. While it was readily agreed there was no objective evidence of knee instability to warrant a rating under the 5257 code (knee, other impairment of), there was considerable debate regarding whether sufficient evidence was present to warrant application of §4.40 (functional loss) or §4.59 (painful motion). The Board also carefully considered the option of rating both knees together at 10%, (the approach taken by the PEB, although at 0%) and supported under VASRD §4.71a. Ultimately, the Board majority 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 recommends a disability rating of 10% for the bilateral knee pain condition, coded 5099-5003.

Chronic Neck Pain Condition. Review of the STR indicated the CI was in a motor vehicle accident in August 2003 and subsequently experienced chronic neck pain not associated with a surgical indication. Imaging studies showed small disc bulges at C5-6 and C6-7, and mild left foraminal narrowing at C6-7.

At an outpatient visit on 22 November 2005 (6 months prior to separation) the CI complained of a 5-day history of worsening neck and left shoulder pain, and sudden episodes of decreased strength. Examination showed tenderness of the left trapezius muscle and normal upper extremity muscle strength.

At the MEB exam, the CI complained of loss of feeling and tingling in the left arm and shoulder. He stated that “multiple times” he lost complete use of the left arm. Examination showed “slight pain” of the neck with motion. Neurologic exam was normal. The NARSUM evaluation reported left shoulder radicular pain and a complaint of occasional loss of sensation in the left upper extremity. Physical exam revealed a normal gait. Neck spasms were present, but spinal contour was not mentioned. Muscle strength and sensation was normal. Range-of-motion (ROM) testing revealed cervical flexion of 50 degrees (normal to 45 degrees) and combined ROM of 280 degrees (normal to 340 degrees).

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the 5237 code (cervical strain). The VA also rated the condition at 10%, but used the 5243 code (intervertebral disc syndrome). Board members agreed that the PEB’s 10% rating was appropriate given the limitation of combined motion (i.e. greater than 170 degrees but not greater than 335 degrees). Although muscle spasm was noted by the NARSUM examiner, there was no requisite link to abnormal gait or spinal contour to support the next higher 20% rating. The Board also deliberated whether a higher rating could be achieved under the formula for rating intervertebral disc disease based on incapacitating episodes, but could not find sufficient evidence which would meet the minimum criteria under that formula. The Board finally considered if additional disability was justified for a history of left upper extremity radiculopathy. The CI complained of intermittent numbness and weakness to the left arm. However, examinations recorded normal muscle strength. The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. There is no evidence in this case of functional impairment attributable to peripheral neuropathy. While the CI experienced some radiating pain, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” The Board therefore concludes that additional disability was not justified on this basis. 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 neck 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 chronic bilateral anterior knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic bilateral anterior knee pain condition, the Board by a majority vote recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the chronic radiating neck 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Bilateral Knee Pain 5099-5003 10%
Chronic Radiating Neck Pain 5237 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140415, 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 XXXXXXXXXXXXXXXXXXXX , AR20150014206 (PD201402189)
1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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