RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-00277
BRANCH OF SERVICE: ARMY 	SEPARATION DATE:  20070913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2 Infantryman, medically separated for “right wrist pain” and “stress fractures of the left proximal tibia with persistent left knee pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  The CI contended that his TBI and PTSD had worsened.  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 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 - 20070824	VARD - 20120607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Pain	5099-5003	10%	Right Hand Injury	8515	NSC	STR	
Stress Fractures of Left Proximal Tibia with Persistent Left Knee Pain	5022	0%	Left Knee Condition with Medial Tibial Stress Fracture	5262	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY: 

Right Wrist Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right wrist condition began in April 2007 after falling.  An electromyogram (EMG) nerve conduction study (NCS) was completed on 9 May 2007 that showed “focal neuropathy involving only the dorsal cutaneous sensory branch of the right ulnar nerve.”  

The 20 June 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of wrist pain and sensitivity.  The CI wore a right wrist brace.  The physical examination showed loss of active extension of the right wrist, an inability to bend the 4th and 5th digits, and marked decrease in grip strength.  There was tenderness to palpation at the outer aspect of the right wrist.  It was noted that the CI was right hand dominant.

The 11 July 2007 occupational therapy examination showed active ROM of the right wrist extension (palmar flexion) to 55 degrees (normal 80), flexion (dorsiflexion) to 60 degrees (normal 70), and 15 degrees of ulnar and radial deviation (normal 20).  There was no VA examination in evidence proximate to separation.  There was no VA examination.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist pain condition 10%, coded 5099-5003 (arthritis, degenerative) citing “range of motion and grip limited by pain.”  The CI’s grip strength was noted as “markedly decreased grip strength and severe mobility limitation due to pain.”  Right wrist extension was noted as decreased.  The CI was observed wearing a wrist brace.  AN EMG/NCS substantiated the findings of hyperesthesia and decreased strength as it showed “focal neuropathy involving only the dorsal cutaneous sensory branch of the right ulnar nerve.”  The VA did not rate the right wrist condition, indicating that it was not service connected.  
 
The panel considered diagnostic codes 5215 (wrist limitation of motion), 5308 (muscle injury wrist extension, fingers); and 8516 (incomplete paralysis of the ulnar nerve).  There was insufficient wrist limitation of motion for a rating under 5215. Panel members agreed that the EMG findings of ulnar neuropathy with decreased ROM and grip strength met the criteria for a 10% rating under 5308.  There was no route to a rating higher than 10% PEB rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right wrist condition.  

Stress Fractures of the Left Proximal Tibia.  According to the STR and the MEB NARSUM, the CI’s stress fractures of the left proximal tibia began in March 2007 after falling and twisting his left knee.  The 20 June 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain and swelling of the left knee.  The examiner annotated that a bone scan performed on 23 March 2007 showed a “stress fracture at [the] upper metaphysis of left tibia and in left calcaneal bone.”  Physical examination showed marked tenderness to palpation around the left knee and the bilateral pre-patellar area.  The examiner noted the presence of some patellar grind and slight swelling under the patella.  The ROM of the left knee was limited with pain and the CI ambulated with an altered gait.  The examiner noted that the CI was “unable to put full weight on leg without severe pain and feels like giving out.”

The 11 July 2007 Occupational Therapy ROM examination showed flexion of 130 degrees (normal 140) and extension of -8 degrees (normal 0).  The CI was observed “ambulating in hall from rest room to waiting room without his crutch – approx. 20-30 ft.” 

At the 19 July 2007 orthopedic clinic appointment the CI complained of pain, swelling and inability to bear weight on the left knee.  The CI was using crutches to ambulate.  Physical examination showed tenderness to palpation along the medial border of the knee joint.  There was “no associated meniscal signs and a stable joint.”  There was “no soft tissue swelling of the joint and patellofemoral joint” appeared stable.  At the 26 July 2007 rehabilitation and spine clinic appointment, 2 months prior to separation, the physical examination showed full, painless, left knee ROM with joint-line and patellar tenderness.  There was no VA examination.

The panel directed attention to its rating recommendation based on the above evidence.   The PEB rated the stress fractures of the left proximal tibia condition 0%, coded 5022 (periostitis) citing “range of motion limited by pain.”  The VA did not rate the left tibia condition, indicating that it was not service connected.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §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 proximal tibia condition, coded 5022.  

BOARD FINDINGS:  In the matter of the right wrist condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left proximal tibia condition, the panel majority recommends a disability rating of 10% coded 5022 IAW §4.71a.  The single voter for dissent recommends no change and elected not to submit a minority opinion.  There are 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	
Right Wrist Pain	5099-5003	10%	
Stress Fractures of the Left Proximal Tibia with Persistent Left Knee Pain	5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, w/atchs
Exhibit B.  Service Treatment Record

AR20170015250, 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