RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00322
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “chronic pain right leg…” with a disability rating of 0%.

CI CONTENTION:  The CI reports his condition continues to worsen and negatively impact daily activities, and that he should be rated 20% for the condition.  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 - 20011214	VARD - 20050120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Right Leg…	5099-5003	0%	Status Post Fracture of the Right Tibia	5262	10%	20040902	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Pain Right Leg.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in July 2001 associated with a road march during basic training.  He was transported to the Emergency Room and obtained treatment as well as radiographs.  Radiographs revealed a tibial shaft fracture.

The CI leg was put in a cast for approximately 8 weeks when near the end of that time on 12 September 2001, he reinjured himself by placing all of his weight on his right lower extremity, and executing a twisting motion.  Repeat radiographs revealed a new fracture.  The CI was placed back into a long-leg cast on 14 September 2001 for approximately 2 months until November and then back into a short-leg walking cast until December 2001.  There was no surgical indication.

The MEB NARSUM, 28 November 2001 (2 months before separation), noted mild edema with tenderness to palpation at the mid tibial shaft.  The examiner also noted “compartments were soft in the lower leg as well as the foot”, and “there was normal ankle movement as well as normal knee motion.”  Radiographic studies showed a definite fracture line still present.  The examiner viewed it as “a stable fracture, but not completely healed radiographically, however, clinically he was healed.”

There was no VA Compensation and Pension (C&P) evaluation proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded analogously as 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA examination was too remote from date of separation for the panel’s consideration.

There was no evidence of painful 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 minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 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), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  

There was no limitation of motion (5260, 5261), and no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  Finally, there was no evidence of ligamentous instability or laxity which warranted a rating under the 5257 code.  The panel was unable to find a path to a higher rating under any applicable code. 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right leg pain condition.

BOARD FINDINGS:  In the matter of the right leg condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the Board’s scope of review for consideration.  

The panel, 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 20160428, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170015276, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
						      					
Enclosure