RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00111
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Water Treatment Specialist) medically separated for chronic pain in left thigh and knee.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left distal femur fracture” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain in left thigh and knee” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his conditions by the VA.  His conditions continue to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

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:  

Admin Corr - Dated 20080411	VA* - (~2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in Left Thigh and Knee	5299-5255	10%	Residuals, Gunshot Wound, Left Femur (also claimed as knee injury)	5299-5255	10%	20080207	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080806 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Pain in the Left Thigh and Knee Condition.  The service treatment record (STR) indicated the CI presented to a civilian hospital on 2 March 2007 after his 45-caliber service revolver, which he was cleaning, discharged in his left knee.  In the operating room he was found to have an entrance wound through the vastus medialis muscle, which appeared to be grossly intact with minimal damage and a severely comminuted intraarticular left distal femur fracture with evidence of shrapnel and comminution of the condyles.  Bone fragments and bullet fragments were removed and the articular surface was reconstructed.  A large bone deficit was present behind the condyles and grafting was delayed.  Two days later in the operating room the wound was explored and the bone defect was grafted with Norian (calcium phosphate).  His postoperative course was benign although he had a decreased hemoglobin level, which stabilized without a transfusion.  He was discharged on 8 March 2007 with medication to prevent a deep vein thrombosis and for pain.  By 20 March 2007 his range-of-motion (ROM) was from 0 to approximately 40 degrees and a strict non-weight bearing status was maintained.  On 24 April 2007, his ROM was approximately 5 to 65 degrees, but he had not regained motion as quickly as anticipated raising potential causes including the severity of injury, heterotopic bone formation (outside of the fracture), symptomatic hardware, or arthrofibrosis (excessive scar formation).  On 3 May 2007, the CI underwent an examination under anesthesia with arthroscopy of the left knee, a quadricepsplasty (to surgically release adhesions), lysis of adhesions of the left knee with manipulation, and removal of hardware. Postoperative rehabilitation and physical therapy continued as did regular orthopedic follow-up visits through 5 December 2007 when left knee flexion was 122/122/123 degrees with no pain compared to right knee flexion of 130 degrees three times and left extension was 0 degrees three times with no pain compared the right knee, which was also 0 degrees.  There was no instability (Lachman 1+ (less than 5 mm) of either the left or right knees.  An X-ray series of the left femur dated 30 January 2008 show a healed open reduction and internal fixation of the distal femur.    

At the MEB examination dated 7 November 2007, the CI reported “all conditions resulting from gunshot wound” in response to questions 12g.-n.  On the DD Form 2807-1.  The MEB physical examiner noted a decreased ROM of the left knee and “scar left knee/thigh.”  A permanent L3 profile was issued on 9 November 2007 for a gunshot wound to [left] femur to initiate an MEB as well as with limitations of all army physical fitness testing and military functional activities except wearing a protective mask and all chemical defense equipment.  The commander’s statement dated 13 November 2007 indicated his injury was the result of an accidental gunshot wound and the CI was diagnosed with both a shattered femur and having residual shrapnel in the knee. He was unable to complete required tasks due to frequent pain in his extremities and the pain seemed to worsen after physical activity.  He was unable to stand for long periods of time, carry objects in excess of 25 pounds, stoop or kneel, or deploy with his unit. 

The MEB narrative summary (NARSUM) dated 7 December 2007 noted the CI complained of “continued left knee and leg pain, inability to run and stand for long periods, and sharp pain 6/10 [10 being the worst pain], going down stairs.”  He was status post a gunshot wound to the left knee while cleaning his pistol, which discharged into his left knee.  Post-surgery and physical therapy, he still complained of significant pain in his left distal femur.  On examination he had well-healed scars about the distal femur with the ROM approximately 0 to 110 degrees of knee flexion without instability.  He complained of global moderate tenderness to palpation about his knee and was neurovascularly intact distally.  He had 2+ pulses distally and ambulated with a slight limp.  The left distal femur fracture with the resultant left distal femoral pain and arthritis affected his ability for both manual and sedentary work in the military due to his pain, weight bearing intolerance, and problems with his gait.

At the VA Compensation and Pension (C&P) examination dated 7 February 2008, performed 2 months before separation, the CI reported he accidentally shot himself while cleaning his pistol after he went to the firing range.  He had extensive corrective surgery, but after participating in training, he could not run secondary to extreme pain and locking of his left knee.  The examiner noted a keloid scar about 1cm in length and about 0.5cm in depth with mild tenderness of the scar area with some loss of tissue of the left upper thigh; however the CI had a good ROM.  There was no evidence of spasm, tightness, or swelling of the left thigh.  He had an extension of -8 degrees with pain and stiffness and mild instability noted between -8 to -4 degrees with a mild limitation of motion of the knee, but no evidence of lack of endurance or fatigability with repetition.  Flexion was 0 to 140 degrees with pain and stiffness starting at 120 degrees and ending at 140 degrees.  There was no evidence of lack of endurance or fatigability and there was no evidence of limited ROM on flexion.  He had mild instability with manipulation, but there was no evidence of an effusion or swelling.  He had a mild Lachman’s test (to determine instability), but was negative for McMurray’s test (to determine a meniscal tear).  He also was negative for an anterior drawer sign (to determine instability related to the ACL) with repetition.

On 28 April 2008, 19 days post-separation, the CI had an Emergency Department visit for feeling a clicking sound, pain with full flexion of the knee, and pain walking up and down stairs after twisting his knee while walking 1 day earlier.  X-rays were negative for a fracture.  Crutches and an ace wrap were provided along with medication for pain and a referral to orthopedics.  At an orthopedic follow-upon 28 May 2008, but he had no click or locking, although the knee felt subjectively unstable and he had numbness at the lateral aspect.  Examination revealed about 5 to 10cc’s of effusion and tenderness to palpation over his medial femoral condyle and his medial joint line.  His ROM was from about 5 degrees to about 115 degrees without instability or evidence of a meniscal tear.  However he had about 50% of quadriceps atrophy, but was able to squat without any significant discomfort.  X-rays showed some slight medial joint space narrowing, consistent with possible early posttraumatic arthritis.  Additional quadriceps strengthening was recommended. An X-ray series on 30 June 2009 showed hardware within the distal left femur and numerous punctate metallic densities were present within the medial femoral condyle and intercondylar notch.  A tiny osteophyte was present on the posterior superior aspect of the left patella (kneecap) and minimal heterotopic ossification anterior to the distal shaft of the left femur was also noted.  On 28 October 2009, an MRI of the left knee revealed the posterior cruciate ligament was thickened consistent with a partial tear, a severe loss of the articulating surface cartilage in the medial femoral condyle and two areas of osteochondral lesions, and a complex tear of the lateral meniscus and a horizontal tear of the medial meniscus.  An orthopedic examiner noted it was difficult to see much on the MRI and on examination found crepitus with the ROM, which was from 0 to 115 degrees with no instability, and no flexion McMurray (to determine a meniscal tear).  Progression of arthritis and the need for a total knee replacement were reviewed including options of cortisone injection or viscosupplementation and weight control.  

The 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.

Left Knee ROM
(Degrees)	PT ~4 Mo. Pre-Sep
	MEB ~4 Mo. Pre-Sep
	VA C&P ~2 Mo. Pre-Sep
	
Flexion (140 Normal)	122/122/123	110	140	
Extension (0 Normal)	0/0/0	0	-8	
Comment	No pain	Lachman/1-A; global moderate tenderness to palpation about the knee	Mild instability between -8 and -4 degrees, painful motion 120-140 degrees; 	
§4.71a Rating	0%	10%	VA 10%	
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5299-5255 (Femur impairment) for chronic pain in the left thigh and knee as a result of an accidental self-inflicted gunshot wound (with personal weapon).  The VA likewise assigned a 10% rating using code 5299-5255 for residuals of a gunshot wound of the left femur.  The Board sought a route to a higher rating and noted at the VA examination there was painful motion in a noncompensable ROM for flexion as well as mild instability reported.  Combined ratings of the knee can be recommended IAW the opinion of the VA Counsel General dated 1 July 1997.  Therefore, the Board considered the use of code 5099-5003 (degenerative arthritis) with a 10% rating combined with code 5257 (Knee, other impairment-slight subluxation) with a 10% rating.  The Board members deliberated whether the VA finding of mild instability rose to be separately unfitting thereby warranting an additional rating.  The Board also considered code 5299-5255 with moderate knee disability in view of the combination of painful motion, mild instability, and quadriceps atrophy as well as early arthritic changes.  The Board is aware that the CI had a twisting injury to the left knee shortly after separation and more than a year later there were MRI findings that were inconsistent with orthopedic clinical findings.  Because of the disparate findings and the time beyond separation of greater than 12 months, the Board is unable to determine an additional rating related to the twisting injury and its residual changes.  The Board also considered using a muscle code 5314 (Group XIV) since the bullet penetrated the vastus medialis (vastus internus), albeit the damage was minimal.  However, VASRD §4.56(a) (Evaluation of muscle disabilities) states:  an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal.  Additionally, §4.56(c) states “For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, incoordination and uncertainty of movement.”  Therefore, although the muscle injury could not be rated as severe, it had some features of a moderately severe disability, but the record did not objectively demonstrate the cardinal signs and symptoms of muscle disability making the use of code 5314 or the analogous code less than likely to be applicable or assignable.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board consensus was that a disability rating of 10% for the chronic pain in the thigh and left knee condition was appropriately recommended in this case and there was insufficient cause to recommend a change in the PEB adjudication.  

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 AR 635-40 for rating chronic pain of the left thigh and knee was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the chronic pain in the left thigh and knee condition and IAW VASRD §4.71a, the Board majority 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 20131120, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
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 XXXXXXXXXXXXXXXXXXXXX, AR20160002030 (PD201400111)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA