RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03671
BRANCH OF SERVICE:  Army	BOARD DATE:  20150206
SEPARATION DATE:  20080822

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for a right thigh muscle injury.  The muscle injury could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The muscle condition, characterized as “chronic right thigh pain with a history of recurrent right quad strain,” was forwarded as the sole condition to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “muscle group injury, Group XIV” as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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:

Service IPEB – Dated 20080625	VA (9 Mo. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Muscle Injury, Group XIV	5314	10%	Right Leg Condition	5314	NSC	20090514	
Other x 0 (Not in Scope)	Other x 13	
Rating:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20090820 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Muscle Condition.  The earliest entry in the available service treatment record (STR) is from January 2005, reflecting a suspected right quadriceps strain injury following a road march.  There are STR entries over ensuing months documenting pain, limited range-of-motion (ROM), and antalgic gait; which improved over time.  Magnetic resonance imaging performed in April 2005 noted significant strain injury to quadriceps muscles, but no indication of a muscle tear.  An orthopedic consultant the following month recommended continuing physical therapy (PT) and activity restriction.  There are no entries in the available STR referable to right thigh complaints for the ensuing 3 years.  There is a PT entry from November 2007 (9 months prior to separation) which documents a re-injury of the right quadriceps.  It records 4/5 quadriceps strength, notes that the CI was able to perform 20 straight leg raises, and contains the entry “tenderness to palpation mid-quad muscle belly; area of hardness – probable scar tissue.”  There are follow-up PT notes repeating these findings, with an entry from February 2008 stating, “Believes thigh pain is worsening.  Unit is pressuring him to resolve issue.”  There are no other probative STR entries preceding the narrative summary (NARSUM) by orthopedics.

The NARSUM was conducted on 7 June 2008 and notes baseline right thigh pain rated 4/10; with exacerbations to 8-9/10 by “running, jumping, marching, walking up stairs” and load bearing.  The NARSUM physical exam recorded a “non-antalgic [normal] gait ... 5/5 muscle strength ... no swelling ... mild tenderness ... no area of hardness or indurations.”

A VA Compensation and Pension (C&P) examination was conducted on 11 May 2009, 9 months after separation, and conveyed an impression that the muscle condition was fully resolved.  The VA examiner stated, “The patient states that he is currently doing fine.  The patient complains of no pain or function deficits due to this traumatic event.  No effect on daily activities or occupation.  The average pain is 0/10.”  The VA physical exam documented normal gait, 5/5 strength at the thigh and knee, no muscle atrophy or defects, full painless ROM, and no “pain, weakness, incoordination, fatigability, lack of endurance” with repetitive motion.

The Board directed attention to its rating recommendation based on the above evidence.  All members agreed that the PEB assigned 5314 (Group XIV) is the appropriate (anatomically accurate) muscle code for rating the disability in this case.  The PEB’s 10% rating was for “moderate” muscle disability under that code, which also confers a 30% rating for “moderately severe” and 40% for “severe” muscle impairment.  The VA’s rationale for denial of the condition was premised on the normal C&P findings, stating “no permanent residual or chronic disability ... demonstrated by evidence following service.”  Members turned to deliberation of whether a higher rating under 5314 could be reasonably recommended.  VASRD §4.56 (evaluation of muscle disabilities) defines the cardinal signs and symptoms of muscle disability as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.”  A moderate rating (PEB determination) is for “record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability ... particularly lowered threshold of fatigue after average use.”  The rating for moderately severe disability requires “record of consistent complaint of cardinal signs and symptoms of muscle disability ... and, if present, evidence of inability to keep up with work requirements.”  All members agreed that the criteria for a severe rating under §4.56 were not reasonably satisfied in this case.  With regard to the cardinal signs, the NARSUM and STR evidence provides support for fatigue-pain, but no others.  The 30% language for cardinal signs (plural) is thus not satisfied; and, the 30% requirement for “inability to keep up with work requirements” appeared to be applicable to more rigorous soldiering requirements, but not for routine occupational demands (as strongly supported by the VA evidence).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board therefore concluded that there was insufficient cause to recommend a change in the PEB adjudication of the right quadriceps muscle 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right gastrocnemius muscle condition and IAW VASRD §4.46, 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, 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 20140731, 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 XXXXXXXXXXXXXXX, AR20150011219 (PD201403671)

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:

Encl			     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA