RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00296
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070703

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Multichannel Transmission Systems Operator-Maintainer Trainee, medically separated for “left thigh and knee pain” with a disability rating of 10%.  

CI CONTENTION:  “Please review all conditions.”  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 - 20070606	VARD - 20080128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Thigh and Knee Pain Status Post … Intramedullary Rod Placement (Femur)	5099-5003	10%	Left Femoral Stress Fracture	5252	10%	20070927	
			Residual Scarring from Placement of Left Femur Rod	7804	10%		
			Left Knee	5260	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Thigh and Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent an intramedullary rod placement for prophylactic nailing of her recurrent left femoral stress fracture in January 2007.  During the 26 March 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported left leg and left knee pain with increased pain on bending or straightening the knee where the screws were.  Physical examination showed the CI walked with a limp.  There was marked decreased left hip range of motion (ROM) and moderate decreased left knee ROM due to pain.  

The 26 March 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic left leg pain secondary to stress fracture of femur, status post intramedullary rod and nailing in January 2007 and left knee pain.  The CI indicated she required crutches for long distance walking.  X-rays showed a left femoral intramedullary rod with three screws and areas of new forming bone; the left hip and knee joints appeared normal.  Physical examination showed the CI walked with a moderate limp.  The left thigh had well-healed scars.  There was tenderness in the left trochanter, and pain and mild tenderness in the distal thigh.  There was slightly decreased motor strength of +4/5 (normal 5/5) in the left quadriceps and hamstrings.  The left knee had “full” ROM in the NARSUM text and slight ROM limitation in the NARSUM-cited PT ROM evaluation, charted below.  

At the 27 September 2007 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported constant pain in her left leg and hip, and walked with a limp that increased toward the end of the day.  She had no rehab since her surgery.  She also had knee popping/catching with swelling once a month where she would have to stay off of her feet for one to two days.  Physical examination showed “full active and passive range of motion in the hip without pain.”  Measured ROMs had some pain at end points as charted below.  She had some pain at the end point, but no fatigue or incoordination with repetitive motion.  The left knee had no laxity or instability.  There was no pain, fatigue or incoordination with repetitive motion.  There were two well-healed distal scars just superior to the knee from where the interlocking screws were placed.  Each scar was 1 inch in length, not hypertrophied, non-tender, and not adherent to underlying tissue.  “However, deep to the scars the interlocking screws are palpable and tender to touch.”  X-rays of the left knee were normal.  X-rays of the left femur showed an intramedullary nail with two distal interlocking screws and evidence of a healed fracture.  

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Hip (Thigh) ROM
(Degrees)	PT/MEB ~3 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Flexion (125 Normal)	34, 36, 39	120	
Extension (20)	13, 12, 14	20	
External Rotation (45)	20, 19, 21	70	
Abduction (0-45)	20, 24, 25	30	
Adduction (45)	15, 19, 20	20	
Comment	Painful motion	Pain at end points	
§4.71a Rating	10%	10%	

Left Knee ROM
(Degrees)	PT/MEB ~3 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Flexion (140 Normal)	130	135	
Extension (0 Normal)	0	0	
Comment	No pain; NARSUM “full”	No effusion, no instability; no tenderness	
§4.71a Rating	0%	0%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left thigh and knee pain condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing full ROM and application of the US Army Physical Disability Agency pain policy.  The VA rated the left leg condition 10% coded 5252 (thigh, limitation of flexion of), citing limitation of motion, and the VA additionally rated the residual scarring (tender, palpable screws) from placement of left femur rod at 10% under code 7804 (scar(s), unstable or painful).  The VA also adjudicated the left knee condition as not service-connected citing a normal knee examination with no disability diagnosed.  

There was no evidence of painful knee motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of knee flexion or extension (5260, 5261).  There was compensable limitation of hip motion under code 5252 at the MEB examination (flexion limited to 45 degrees [10%], but not limited to 30 degrees [20%]), but no compensable limitation of motion under codes 5250 thru 5253 by the time of the C&P examination.  However, there was clear objective evidence of painful motion causing functional loss (based on §4.59, §4.40 and §4.45) at both the NARSUM and VA examinations supporting a 10% rating.  

There was surgery of the left femur with residuals to support consideration of alternative rating under the analogous code for hip and knee impairment related to long bone conditions (5255 - femur, impairment).  The panel deliberated if the functional loss and pain; including tenderness to palpable surgical screws/scar, and a sustained limp more closely approached the “moderate knee or hip disability” (20%) disability picture under code 5255, or if the surgical screw tenderness was separately unfitting and ratable.  

The panel consensus was that the CI’s left thigh and knee pain was best rated at 20% analogous to code 5255, rather than 10% for the painful motion of the hip and 10% for the painful thigh screws/scars.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the left thigh and knee pain condition, coded 5299-5255.  

BOARD FINDINGS:  In the matter of the left thigh and knee pain condition, the panel majority recommends a disability rating of 20%, coded 5299-5255 IAW VASRD §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	
Left Thigh and Knee Pain Status Post … Intramedullary Rod Placement (Femur)	5299-5255	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160223, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015256, 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