RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01906
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E2, Trainee, medically separated for “left distal femur pain…due to distal femur stress fracture…with left knee pain,” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  The 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 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 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 determinations 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 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 - 20060918	VARD - 20150108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Distal Femur Pain…Due to Distal Femoral Stress Fracture…with Left Knee Pain	5099-5003	0%	Residual Left Femur Fracture with Left Hip Pain	5255	30%	20140927	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY: 

Left Distal Femur…Due to Distal Femoral Stress Fracture…with Left Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), in December 2005, prior to entry on active duty, the CI injured his left knee in a motor vehicle accident and was hospitalized.  The CI also reported a history of chronic left knee pain that started in high school.  The records indicate the CI re-enlisted with a waiver to the normal 24 month wait requirement before re-enlistment which was approved on 28 November 2005.  The CI’s left distal femur stress fracture was found on X-ray on 5 June 2006 as a result of left knee pain complaints.  Radiographic studies on 13 July 2006 showed increased callus formation and sclerosis of the distal left femoral stress fracture.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded left distal femur stress fracture and chronic left knee pain patellofemoral pain syndrome for PEB adjudication.  Range of motion conducted by physical therapy on 13 July 2006 showed left knee ROM following repetitive movement was 131 degrees flexion (normal 140) and 0 degrees extension (normal 0) with pain compared to the right knee ROM of 0-130 degrees.  A mild antalgic gait was noted.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated July 2006, 2 months prior to separation, the CI reported left knee pain and left femur stress fracture.  The CI also reported a left knee ligament injury in December 2005 after a motor vehicle accident.  Physical examination showed an abrasion scar on the left knee.  The MEB NARSUM examination on 1 August 2006, 2 months prior to separation, noted original complaints of left knee pain without trauma.  In June 2006 the left distal stress fracture was identified.  The CI was treated with physical therapy and convalescent leave, but the left knee pain continued.  The CI reported left knee pain rated 6/10 that increased to 8/10 with prolonged walking or standing.  Physical examination showed a normal left hip.  There was localized tenderness to the distal femur and inferior patellar tendon.  There was no left knee swelling or medial or lateral joint line tenderness.  Strength was normal.  McMurray, Lachman, laxity and drawer testing were negative.  Gait was antalgic and the CI was ambulating on crutches.  The VA Compensation and Pension (C&P) evaluations were on 27 September 2014 and 8 December 2014.  These examinations were too remote from separation to add any probative value.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left distal femur stress fracture condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The PEB also determined the left knee pain was EPTS in origin and not permanently aggravated and cannot be separated from the distal femoral pain.  The VA examinations were too remote for consideration.  The Army PEB listed left distal femur pain…due to distal femur stress fracture…with left knee pain as related diagnoses which contributed to the disability in this case.  The CI had been previously discharged for bilateral knee pain during basic training 19 months prior reentering active duty.  His entry examination was normal and his prospective unit commander noted that he was fully recovered following physical therapy.  Prior to the distal femur stress fracture x-ray findings the CI was diagnosed with patellofemoral syndrome for his knee pain.  The panel agreed that the  distal femur stress fracture and left knee pain were diagnoses related to the left distal femur pain and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  There was no non-union, or malunion fracture of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, the panel concluded that there was sufficient evidence of painful motion and functional loss to support a 10% rating for each knee IAW §4.59, §4.40 and §4.45.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left distal femur stress fracture condition, coded 5255.  

BOARD FINDINGS:  In the matter of the left distal femur stress fracture condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Left Distal Femur Stress Fracture with Left Knee Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150708, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009280 , XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure