RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00404
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080209

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light Wheeled Vehicle Mechanic, medically separated for “chronic pain, left lower extremity following medial and lateral fasciotomies for removal of shrapnel and release of compartments” with a disability rating of 20%.

CI CONTENTION:  “PTSD, hearing loss, chronic pain of the knees and left leg were never addressed by US Army Medical teams.  Chronic headaches are also an issue found to be from slight TBI injury.”  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a 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:

SERVICE PEB - 20090129	VARD - 20080602	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Lower Extremity	5099-5003	20%	Residual Pain and Numbness from Left Midshaft Fracture of the Tibia s/p Bilateral two Incision Fasciotomy	5262-8522	20%	20070711	
			Left Quadriceps Tendonitis	5024-5260	10%	20070711	
			Left Lower Extremity Residual Scars S/P Bilateral Fasciotomies	7804	10%	20070711	
			Left Foot Plantar Fasciitis with Pes Planus…	5276-5024	10%	20080321	
PTSD	Not Unfitting	PTSD	9411	30%	20071103	
Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	NSC	20071109	
Headaches	Not Unfitting	Chronic Headaches…	8045-8100	0%	20070711	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Chronic Pain, Left Lower Extremity.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left leg condition began in October 2006 after being struck by mortar shell fragments.  The CI had a left open non-displaced tibia fracture and underwent lateral and medial fasciotomies (surgically open the leg compartments - and kept open).  He was evacuated from theater and underwent multiple procedures to clean the wounds (“irrigation and debridements and washout”) with delayed primary closure of both fasciotomies.  The CI had continued left lower extremity pain and weakness that did not resolve with therapy or medication use.  The “left lower extremity limb pain, status post shrapnel injury of left leg” was forwarded to the PEB.

At the MEB examination (recorded on DD Forms 2807 and 2808) in June 2007, 8 months before separation, the CI reported left foot tibia and knee problems following a mortar blast.  The physical examination as well as the examiner’s summary and elaboration of history were stamped “See VA Dictation.”  The MEB examination was signed by the same examiner who performed the VA Compensation and Pension (C&P) examination (below).

At the VA C&P examination in July 2007, performed 7 months before separation, the CI reported pain and swelling in the left lower extremity, numbness from below the knee to above the ankle, and sensitive scars.  He had bilateral knee and ankle pain and had been diagnosed with quadriceps tendonitis.  Symptoms were aggravated by prolonged walking, carrying items over 25 pounds, and prolonged sitting.  Relieving factors, rest and elevation and medications (including neuroactive medication – Gabapentin/Lyrica), were ineffective.  The CI had chronic pain of 4/10 and at least once a day flare-ups to 8/10, and he could not wear socks going above the ankle or boots due to pain and swelling.  The physical examination showed that the CI had a normal gait with painful knee motion of 0-125 degrees (normal 0-140), significant patellar crepitus, and no tenderness, laxity or instability.  There was additional pain, but no other deficit or decrease in motion following repetition (DeLuca).  There was no specific ankle examination.  Lower extremity strength and reflexes were normal and no neurologic deficit was noted.  The CI’s multiple left lower extremity scars (30x1.5 cm and 24x0.8 cm) were tender to touch.  Diagnostic imaging of the left knee and ankle were normal.

At the NARSUM, dated the day following the VA C&P examination (7 months before separation), the CI’s chief complaint was left lower leg pain; he could not maneuver around vehicles or lift heavy objects and had difficulty climbing stairs, wearing open toed shoes, being on his feet all day, or with prolonged walking.  The examination stated the CI had “full range of motion about the knee with no knee pain.  He has 20 degrees of dorsiflexion.  He has got 35 degrees of plantarflexion.  He has good eversion and inversion strength of 5/5.”  The scar lengths were similar to the VA measurements (30x2 cm and 23x1 cm), and the remainder of the exam focused on the paresthesias and numbness in the superficial peroneal and medial cutaneous branches of the saphenous nerves.  The CI’s L3 profile included modified sock wear.

A physical therapy evaluation of the left ankle also performed in July 2007 documented pain-limited motion with dorsiflexion of 10 degrees (normal 20) and plantar flexion to 40 degrees (normal 45).  No knee measurements were accomplished.

At the VA C&P feet examination in March 2008, performed 1 month after separation, the CI reported continued left foot pain that started when he began walking without cast or crutches in December 2006.  Pain was constant 4-5/10 and increased to 8-9/10 with walking or standing over 10 minutes.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under an analogous 5003 code (arthritis, degenerative), citing “rated as moderate/constant.”  The VA assigned multiple ratings to the left lower extremity condition.  A 20% rating for residual pain and numbness from left midshaft fracture of the tibia coded 5262-8522 (tibia and fibula, impairment of - musculocutaneous nerve [superficial peroneal], incomplete paralysis) based on the VA C&P examination 7 months before separation, citing incomplete paralysis of foot movement which is severe.  A 10% rating for left quadriceps tendonitis coded 5024-5260 (tenosynovitis-leg, limitation of flexion of) citing painful limitation of flexion.  A 10% rating for left lower extremity residual scars coded 7804 (scars, superficial, painful on examination).  A 10% rating for left foot plantar fasciitis with pes planus coded 5276-5024 (flatfoot, acquired – tenosynovitis).

The Board noted that the VA examinations were more detailed and provided joint measurements in degrees and addressed repetitive motion IAW VASRD guidance.  The Board considered VASRD compliant ratings (absent the Army pain policy) under various codes applied by the VA for the left lower extremity, as well as potential muscle coding.  However, there was significant overlap of symptoms attributable to nerve, muscle, joint, scar and foot disability with concerns about compliance with VASRD §4.14 (avoidance of pyramiding) and in determining which conditions/codes were unfitting or not unfitting (and not compensable).

The Board adjudged the tibial fracture, fasciotomies and related nerve disability were the predominant factors in the CI’s disability condition and were unfitting.  However, the CI had significant contributions to his left lower extremity pain from symptoms related to the musculocutaneous nerve injury as well as residuals of the scars and ankle joint/tendon and foot disabilities.  The Board considered individually rating the components of the left lower extremity chronic pain disability condition, similar to the VA’s approach, but considering issues of avoidance of pyramiding (IAW §4.14) elected for a single rating under a combined code.  The predominant coding, accounting for the preponderance of the CI’s disability picture, was therefore under the 5262 (tibia and fibula impairment) code with consideration for neurologic issues, and ankle and knee disabilities.  The Board therefore adjudged the CI’s disability picture was best approximated by use of 8722-5262 (neuralgia - tibia and fibula impairment) at the 30% criteria level for severe lower leg disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the left lower extremity condition, coded 8722-5262.

Contended PEB Conditions.  The Board’s main charge was to assess the fairness of the PEB’s determination that post-traumatic stress disorder (PTSD), hearing loss, and headaches were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement and none were judged to fail retention standards.  The commander’s statement specifically noted that the CI was well oriented, was on time, did not have memory loss and made well thought out decisions.  There was no performance-based evidence from the record that any of the contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for PTSD, hearing loss, or headache conditions and no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the left lower extremity condition, the Board unanimously recommends a disability rating of 30%, coded 8722-5262 IAW VASRD §4.124a and §4.71a.  In the matter of the contended PTSD, hearing loss, and headaches conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain, Left Lower Extremity Following Medial and Lateral Fasciotomies	8722-5262	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140105, 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 XXXXXXXXXXXXXXXXXXXX, AR20160010334 (PD201400404)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

c. Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA