RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00435
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantry) medically separated for right groin, right knee and right wrist conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) and he was referred for an Medical Evaluation Board (MEB).  Right groin and right knee and right wrist pain of unclear etiology was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated chronic pain, right groin, knee and wrist conditions as a single unfitting condition, rated 0% citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  He complains of right hip pain “that radiates to my lower back and down to my right knee [and foot, per a later statement]” due to a fracture on active duty.  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 condition outside the Board’s defined scope of review and any contention not requested in this application (including the contended lumbar and foot pain) 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 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:  

Service IPEB – Dated 20041206	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Groin, Knee and Wrist	5099-5003	0%	S/P R Femur Fracture	5255-5252	10%	20050502	
			S/P R Wrist Fracture	5215	10%	20050502	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1 (Surgical Scars) 	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050912 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  As noted above, the PEB included three potentially separate conditions under a single disability rating, coded analogously to 5003 (Arthritis, degenerative).  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 the Board must follow suit 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 service 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.  To that end, the evidence for the right groin, knee, and wrist conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Right Groin Condition (Subsuming Hip with Surgical Femur Fracture).  The service treatment record (STR) corroborates the history in the MEB narrative summary (NARSUM) of a right femur fracture (mid-shaft) from a training accident in September 2002, which mandated surgical fixation.  With persistent pain the CI underwent surgical hardware removal in May 2003 (21 months pre-separation) which was unsuccessful at restoring MOS functionality.  The pain was variously described as “hip” and “groin” pain in the STR.  Post-operative X-rays demonstrated a healed fracture with normal alignment and a normal hip joint.  There is a 2003 STR entry (17 months pre-separation) noting a “slight” antalgic gait, but no subsequent mention of gait disturbance.  There are various STR entries noting grossly normal hip range-of-motion (ROM) and strength (5/5); and, there are no STR entries indicating significant ROM or other functional limitations, joint impingement, neurologic deficits or muscle weakness, or periods of incapacitation after surgical recovery. 

The NARSUM was conducted 27 October 2004 (4 months pre-separation) and documented “pain in the right groin region was unchanged from the preoperative condition...mild, but persistent,” and did not elaborate functional limitations.  The NARSUM physical examination did not comment on gait, and noted “nonspecific” groin tenderness (negative for hernia) but no trochanteric (lateral hip) tenderness.  With regards to hip ROM, the examiner characterized it as “full” but noted “some pain with terminal hip flexion as well as terminal hip external rotation, which reproduces symptoms in the groin.” The L3 profile was for “right hip and thigh pain,” and permitted self-limited running and unlimited walking.  The commander’s performance statement did not provide evidence probative to separate fitness implications of the bundled conditions; but, noted that the CI “conducts daily physical training...while maintaining his own pace during runs and when participating in lower body exercises”; recommending him for retention with re-training to a less strenuous MOS.

A VA Compensation and Pension (C&P) examination was conducted 2 May 2005 (2 months post-separation) and documented “constant pain in the right hip area with intermittent flare -ups throughout the day...usually brought on by performing weight bearing activities such as prolonged walking and standing...has not lost time from his civilian job because of this condition.”  The VA physical examination recorded a normal gait without assistive devices, a non-tender surgical scar, and the absence of hip instability.  The VA measured right hip ROM was flexion to 100 degrees (normal 125, minimum compensable 45), extension to 20 degrees (normal), external rotation of 45 degrees (normal), abduction to 35 degrees (normal 45, minimum compensable 10), and adduction to 25 degrees (normal 45, minimum compensable “cannot cross legs” [~10 degrees]); annotating painful motion.

The Board directed attention to its recommendations based on the above evidence.  The Board first considered if the groin condition, having been de-coupled from the combined PEB adjudication as above, was reasonably justified as separately unfitting as established above.  This condition was profiled, judged to fail retention standards, and was arguably the dominant source of disability in this case.  Members agreed, therefore, that a preponderance of evidence supports a conclusion that the right groin condition was reasonably justified as separately unfitting; and, accordingly a separate rating is recommended.

The Board then turned to deliberation regarding the appropriate coding and rating of the condition.  The evidence makes clear that the adjudicated groin condition is in effect hip pain secondary to the femur fracture, although the latter did not directly involve the joint.  The VA’s 10% rating was under code 5255-5252 (Femur impairment rated as limited flexion of the hip), and invoked painful motion.  With regards to rating the hip joint, there is no directly compensable ROM impairment; but, painful motion is supported by the NARSUM and C&P evidence for achieving the minimum 10% rating, and there is no evidence which would support a higher rating via any alternate joint code available under VASRD §4.71a.  The Board considered alternate rating under criteria of 5255, which offers ratings for contiguous hip disability: 10% for “slight”, 20% for “moderate,” and 30% for “marked.”  This would constitute analogous rating since there was no malunion or nonunion as specified by the code.   Members agreed, however, that the preserved functional capacity (normal gait, limitations primarily with running, no occupational interference) could not be reasonably characterized as moderate disability.  After due deliberation, members agreed that the evidence favors recommendation of the right groin condition (subsuming the hip and femur fracture) as reasonably justified separately unfitting for disability rating; and, mindful of VASRD §4.3 (Reasonable doubt) that it is appropriately rated 10%, proposing code 5255-5010 (Femur impairment rated as traumatic arthritis) for its clinical compatibility.

Right Knee Condition.  There is no evidence in the STR or VA files of a distinct knee condition.  There are STR entries specifically documenting radiating pain to the knee associated with the femur fracture and hip (or groin) pain.  The NARSUM did not ascribe the knee pain to any condition outside its association with the femur fracture, and detailed a normal right knee exam (no tenderness, no effusion, no instability, normal ROM).  As noted above the profile did not specify knee involvement, nor did the commander implicate it.  The post-separation C&P examiner documented “pain...in the right knee...as a result of the fracture,” recorded normal bilateral knee exams (no ratable findings and normal measured ROM), and diagnosed “no evidence of right knee pathology.”  The VA did not service-connect a knee condition for rating.  

The Board directed attention to its recommendation based on the above evidence.  Members agreed that the knee pain did not constitute a separate condition for rating without violation of VASRD §4.14 (Avoidance of pyramiding), since it was intrinsic to and subsumed with the rating already conferred for the femur fracture.  It was further agreed that, even if a separately ratable condition were conceded, there was no performance based evidence reasonably justifying it as separately unfitting; and, beyond that, no ratable findings to achieve a compensable rating even if conceded as unfitting.  After due deliberation, considering all of the evidence, the Board concluded the right knee condition was not reasonably justified as separately unfitting and not ratable.

Right Wrist Condition.  From the same training accident resulting in the femur fracture, the CI sustained a right (non-dominant) wrist fracture (radial styloid) which required surgical pinning.  Post-operative X-rays demonstrated a healed fracture with normal alignment.  There are STR entries documenting grossly normal ROM and normal measured grip strength.  There are no entries to the contrary, and no STR evidence of significant functional impairment or periods of incapacitation.

The NARSUM documented that the CI “denies wrist pain except when the wrist is moved into radial deviation (bent in the direction of the thumb).  He is unable to perform push-ups, but is otherwise unlimited.”  The NARSUM physical examination documented the absence of tenderness or deformity, and normal ROM except for 5 degrees of radial deviation (normal 20, not a ratable criterion under §4.71a) without specifying painful motion.  The condition was not profiled at the time of separation (U1) nor implicated by the commander.

The post-separation VA C&P examiner documented “intermittent flare-ups of wrist pain that occur throughout the day...sometimes uses a brace when he must perform repetitive strenuous physical activities...difficulty performing frequent twisting, torqueing, and heavy lifting and carrying...has not missed work because of this condition.”  The VA physical examination recorded a non-tender surgical scar and no abnormal findings.  The VA measured ROM was dorsiflexion to 65 degrees (normal 70, minimum compensable 15) and palmar flexion to 70 degrees (normal 80, minimum compensable “in line with forearm” [0 degrees]), annotating painful motion (basis of VA 10% rating).

The Board directed attention to its recommendations based on the above evidence, first considering whether the wrist could be reasonably justified as separately unfitting.  It is noted that the Service evidence and NARSUM differ somewhat from the acuity and functional limitations portrayed by the post-separation C&P.  The periodic need for a splint and specific manual limitations noted by the VA examiner could arguably interfere with the CI’s infantry MOS.  Although the condition was not profiled, both the NARSUM examiner and commander (physical training confined to lower body exercises) indicated that there were upper extremity limitations.  Furthermore, the MEB submission and PEB adjudication could be construed as a conclusion that the wrist condition was potentially unfitting in combination with the lower extremity injury.  The limitations with lifting, carrying, and repetitive motion (even with the non-dominant hand) as described by the VA examiner are fairly detrimental for an infantryman; and, it is noted that the VA evidence is temporally closer to separation and more detailed with regard to specific limitations than any of the service evidence; e.g., significantly probative.  Members agreed, therefore, that there is sufficient evidence to support a conclusion that the right wrist condition was reasonably justified as separately unfitting and subject to rating. 

The Board then turned to deliberation regarding the appropriate coding and rating of the condition.  The single code 5215 (Wrist, limitation of motion) is maximally rated at 10%.  The only alternative joint code for the wrist requires ankylosis, which is clearly not applicable.  Members agreed that rating under code 5010 (Arthritis, due to traumatic) was an appropriate resolution, and that the evidence supports application of VASRD §4.59 (Painful motion) to convey the minimum compensable rating of 10%.   After due deliberation and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 10% rating the right wrist condition under code 5010.

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 was operant in this case and it was adjudicated independently of that policy by the Board.  In the matter of the service-combined right groin, right knee and right wrist condition, the Board unanimously recommends that it be re-adjudicated for separate conditions as follows:  An unfitting right groin condition (subsuming the hip and femur fracture) coded 5255-5010 with a disability rating of 10% IAW VASRD §4.71a; right knee pain determined to be not unfitting or ratable; and, an unfitting right wrist condition coded 5010 with a disability rating of 10%; all IAW VASRD §4.71a.  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:

CONDITION	VASRD CODE	RATING	
Surgical Residuals, Right Femur Fracture	5255-5010	10%	
Surgical Residuals, Right Wrist Fracture 	5010	10%	
Pain, Right Knee (Referred from Femur Fracture)	Not Unfitting	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140114, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160002143 (PD201400435)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA