RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01191
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20020609

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Scuba Diver and Marine Systems Operator, medically separated for “femoral neuropathy, status post anterior cruciate ligament (ACL) repair … with a supplementary femoral nerve block” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20020212	VARD - 20020830	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Femoral Neuropathy, status post ACL Repair…with a Supplementary Femoral Nerve Block [Right]	8726	20%	Right Femoral Neuropathy…	8599-8520	20%	20020207	
			Right Knee Injury, status post ACL Reconstruction	5257-5262	10%	20020207	
GERD	Cat III	Duodenitis	7399-7319	0%	20020207	
Plantar Fasciitis	Cat III	Bilateral Plantar Fasciitis…	5284-5276	10%	20020207	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Femoral Neuropathy [Right].  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right lower extremity conditions began in April 1999 due to a traumatic ACL tear that led to instability.  The CI underwent “ACL reconstruction with hamstring tendon” in October 1999 and developed a femoral neuropathy subsequent to a nerve block as part of the right knee ACL surgery.  Diagnostic study (MRI) demonstrated the presence of muscle atrophy without structural lesion involving the femoral nerve.  Electrodiagnostic testing (EMG/NCV) was abnormal, but difficult to interpret and the neurologic specialist indicated clinical findings better described the CI’s condition.  The CI had fallen multiple times including down a ladder and overboard a vessel due to right leg weakness and neuropathy.  

A medical department head summary of the CI’s condition on 19 November 2001, 7 months prior to separation, noted extended light/limited duty with numerous falls or loss of balance due to right leg weakness and neuropathy.  Prognosis was for a permanent disability without expected improvement.  The physician stated “the (CI’s) disabilities compromise the entire spectrum of physical agility and dependable balance and strength in the lower extremities.” Despite oral medications and numerous nerve blocking efforts, the CI had no lasting resolution of right leg pain, paresthesias, and sensory loss.  

The 19 November 2001 MEB NARSUM examination, 7 months prior to separation, noted complaints of right groin and leg pain with weakness and instability.  Physical examination showed normal station and gait.  The CI had difficulty arising from a right leg squat.  Patellar reflex was normal and there were no trophic changes.  There was no obvious atrophy, however right thigh circumference was slightly decreased.  Sensation in all modalities was decreased in the right medial thigh and calf.  The MEB opined that the right femoral neuropathy was permanent and limitations caused by both pain and weakness interfered with duty performance.  

The 29 November 2001 MEB NARSUM addendum examination, 6 months prior to separation, noted complaints of pain and sensory dysthesias in the right quadriceps muscle.  Narcotic pain medication, neuroactive medication and nerve blocks had not provided sustained relief.  Physical examination showed pain with deep palpation on the right anterior and medial aspects of the thigh, decreased sensation in the thigh and medial aspect of the calf and femoral saphenous nerve distribution.  

At the 3 January 2002 MEB examination (recorded on Standard Forms 88 and 93), 5 months prior to separation, the CI reported right ACL surgery and cramps in the legs; lameness; “trick or locked knees;” neuritis; bone joint or other deformity; and arthritis, rheumatism or bursitis.  Physical examination showed decreased right quadriceps and hamstring strength and decreased sensation of the right medial thigh.  Reflexes were normal and symmetric.  The examiner indicated “ACL repair – resolved – right leg gives out secondary to neuropathy.”  

At the 7 February 2002 VA Compensation and Pension (C&P) general evaluation, 4 months prior to separation, the CI reported right lower extremity constant numbness, burning, and tingling; right knee pain, weakness, stiffness, and lack of endurance; as well as right hamstring muscle atrophy and chronic difficulty moving his right knee.  Physical examination showed normal posture and gait.  The right leg had normal muscle strength and reflexes.  There was decreased pinprick sensation in the right femoral nerve distribution “all the way down” in the right lower extremity.  The right knee had crepitus with painful and limited motion of flexion 100 degrees (normal 140) and extension 0 degrees (normal).  There was no instability or laxity and scars were well healed.  X-rays showed screws in the distal femur and proximal tibia.  MRI was reported as showing right hamstring muscle atrophy.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right femoral neuropathy condition 20%, coded 8726 (neuralgia).  The historical statement that the nerve injury was due to anesthesia at the time of ACL surgery was a historical finding and the ACL condition was therefore not in scope.  The VA rated the right femoral neuropathy condition 20%, analogously coded 8599-8520 (sciatic nerve, incomplete paralysis) based on the C&P examination 4 months before separation, citing moderate incomplete paralysis.  

The panel considered if the CI’s right leg peripheral nerve disability warranted any higher rating than the 20% awarded by the PEB and VA.  Deliberations involved determining if analogous ratings under the femoral nerve or sciatic nerve (as coded by the VA) were appropriate, as well as the distinctions between neuralgia and partial paralysis IAW VASRD §4.124a and §4.124 (neuralgia).  

The CI had right leg pain (neuropathic pain), sensory deficits from the upper thigh through the calf, slight muscle atrophy, instability, and difficulty arising from a squat.  The MEB SF 88 examination recorded decreased quadriceps and hamstring strength with SF 93 history indicating symptoms of right lower extremity instability leading to falls and injury.  However, the pre-separation VA examination was closer to separation and indicated sensory deficit and minimal muscle atrophy with normal muscle strength.  

The panel consensus was that the CI’s femoral neuropathy disability was not closer to severe partial incomplete paralysis of the femoral nerve (30%) or moderately severe partial incomplete paralysis of the sciatic nerve, therefore no rating higher than 20% was warranted.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the femoral neuropathy condition.  

Contended PEB Conditions:  Gastroesophageal Reflux Disease (GERD) and Plantar Fasciitis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were part of any limited duty, implicated in the non-medical assessment, or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the femoral neuropathy condition and IAW VASRD §4.124a, the panel majority recommends no change in the PEB adjudication.  In the matter of the contended GERD and plantar fasciitis conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  The single voter for dissent recommended re-characterization and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN