RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00737
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070814

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army National Guard E1, Basic Trainee, medically separated for “mechanical limitation of [left] knee extension...” with a disability rating of 10%.  

CI CONTENTION:  “Ongoing issue with left leg joints at the hip and knee.”  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 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 PEB - 20070706	VARD - 20080122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Limitation of [Left] Knee Extension …	5261	10%	Residuals of Fracture, Left Femur…	5261-5010	10%	20071016	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Mechanical Limitation of [Left] Knee Extension.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left leg condition began on 6 April 2007 while on a road march.  The CI experienced a “snap” associated with severe pain in his left knee and his left leg gave way.  He was found to have a comminuted fracture (multiple pieces) of the left distal femur and a stress fracture of the left proximal tibia.  The CI was taken to the emergency room and underwent an extensive evaluation.  

The CI underwent surgery on 7 April 2007 (4 month prior to separation) and an open reduction internal fixation (ORIF) of the femoral fracture was accomplished without complications.  Radiographic imaging (X-rays) on discharge showed healing stress fracture of the left “tibial plateau” and “near anatomic positioning” of the treated left distal femur fracture with no evidence of stress related injury to the right hip or lower extremity noted.  

Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left leg injury, with residual pain from … proximal tibial stress fracture [and] … distal femur fracture, with ORIF [rod intramedullary]” for PEB adjudication.  

At the MEB NARSUM dated 19 July 2007 (1 month prior to separation), the CI reported he was able to walk without crutches; however, he experienced pain with standing over 10 minutes, walking, and was unable to run.  Post-surgical diagnostic imaging (May 2007) documented the femur as slightly displaced (7.8mm front-to-back).  Physical exam showed “normal” ROM for the hips with some discomfort reported in left anterior hip area with deep pressure.  Measured left hip flexion by the NARSUM examiner using a goniometer was 120 degrees (normal 125) and abduction was 42 degrees (normal 45).  The left knee demonstrated some patellar grinding and persistent pain due to the stress fractures.  The left knee motion was abnormal (lacking 10 degrees of extension), due to his injury.  The CI had a slight limp favoring his left leg with ambulation.  The examiner stated that the CI could ambulate with crutches and anticipated 12-24 months for full healing.  

The VARD summarized that at the VA Compensation and Pension (C&P) examination on 16 October 2007, performed 2 months after separation, the CI reported locking, instability and pain in his left knee.  Physical exam showed that the CI’s left knee ROM was normal with no crepitus.  There was some tenderness to palpation above the knee and no evidence that the CI’s ROM was limited by pain, fatigue, weakness or lack of endurance following repetitive use.  X-rays showed numerous intra-articulate bodies in the left knee.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5261 code (leg, limitation of extension), citing the CI’s “left knee ROM is 10 degree extension lag to 135 degrees of flexion” [passive flexion from MEB].  The VA also assigned a 10% rating using an analogous 5261-5010 code (residuals of fracture, left femur) based on the VA C&P examination 2 months after separation, citing painful motion with X-ray evidence of abnormalities.  

All examinations proximate to separation documented sufficient evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The MEB examination recorded left knee extension limited to 10 degrees following repetitive motion supporting the 10% rating (code 5261) adjudicated by the PEB although the CI was still recovering from surgery.  The VA exam 6 months after surgery documented improved extension, but still supported a 10% disability rating.  There was no limitation of flexion that supported a rating under the VASRD diagnostic code for limitation of flexion (5260) and examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257) for dual rating of the knee.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a higher rating under the meniscal codes.  

Since there was a fracture of the femur and slight post-operative displacement, the Board considered alternative rating analogous to code 5255 (femur, impairment).  Given the slight femur displacement (analogous to malunion) the Board considered if the knee or hip disability was greater than that envisioned in the 10% (slight) rating criteria.  The Board agreed that the disability picture did not approach the marked knee or hip disability picture (30%) and deliberated between the slight (10%) and moderate (20%) disability pictures.  

The Board majority considered that the CI’s continued use of crutches, knee pain and limitations, as well as hip pain, most closely approximated the moderate (20%) disability picture under code 5255.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the left leg condition, coded 5261-5255.  

BOARD FINDINGS:  In the matter of the left leg condition, the Board majority recommends a disability rating of 20%, coded 5261-5255 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Mechanical Limitation of [Left] Knee Extension … Femur … ORIF	5261-5255	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140101, 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 XXXXXXXXXXXXXXXXXX, AR20160006734 (PD201400737)

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