RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01274
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040610

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Military Police, medically separated for “chronic left leg pain” with a disability rating of 0%. 

CI CONTENTION:  The CI detailed conditions that were not diagnosed by the Service.  He continues to have issues with his hips, legs, and sacroiliac joint dysfunction. 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 - 20040504	VARD - 20051018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Leg	5099-5003	0%	Residuals, L/Quadriceps Muscle Tear	5314	0%	20050801	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Pain Left Leg.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left leg pain condition began in July 2002 after she fell off her bike to avoid a car and hit her left side on concrete.  At the Emergency Room on 1 July 2002 she complained of left thigh pain and was unable to bear weight. Examination revealed an abrasion of the anterior aspect of the thigh.  An X-ray showed a normal femur.  Treatment consisted of ice, elevation, and medications for pain.  The CI underwent physical therapy over the next several months.  Swelling of the left thigh decreased, and she was weaned from crutches to a cane.  By 30 September 2002 she had a full range of motion (ROM) of the left hip and knee with tenderness to palpation of the left quadriceps.  At a clinic visit on 1 October 2002 the CI was noted to have a swollen left thigh with tenderness of the left groin and muscles of the thigh.  She was also tender at the left sacroiliac (SI) joint and over the greater trochanter of the femur and was diagnosed as left vastus lateralis (the largest muscle of the quadriceps group) rupture, left SI strain, and total left upper thigh sprain.  The CI underwent a physiotherapy evaluation on 8 November 2002 where it was noted she was limping and not bending her left knee.  She had moderate discomfort over the vastus lateralis and the interior aspect of the thigh.  No bony masses were felt. She had had a good ROM of her hip and with cajoling a reasonable ROM of her left knee, which appeared stable with no mediolateral or anteroposterior instability.  The neurocirculatory status was intact.  The examiner’s impression was a contusion of her left thigh and rule out early myositis (muscle inflammation).  She was referred for aggressive physical therapy and placed on anti-inflammatory medication.  

On 26 November 2002 the CI had improved, but still had significant discomfort in the left thigh with definite residual tenderness in the quadriceps and persistent weakness in the area.  The CI continued to have pain and little response to physical therapy.  On 7 January 2003 she was tender over the lumbosacral spine, SI joint, and adjacent muscles and walked with a limp.  At a pain management visit on 4 February 2003 Pamelor (nortriptyline, an antidepressant medication and for nerve pain) and Celebrex (celecoxib, a nonsteroidal anti-inflammatory drug (NSAID)) were prescribed.  In March 2003 the CI complained of weakness with her left leg associated with pain in the lateral aspect of her thigh, but denied any paresthesias.  Examination of the left lower extremity demonstrated a full ROM of the left hip, knee, ankle, and subtalar joint.   She was weak and had very little strength to resisted extension at the hip area.  No gap within the musculature anterior was noted.  There was mild patellofemoral crepitus (grinding sensation) and no effusion.  The knee examination was within normal limits.  There may have been a slight indentation at the lateral distal third of the vastus lateralis region, but her strength resisted abduction appeared satisfactory.  

On 21 March 2003 a physical therapy examiner noted recent X-rays of the left femur revealed calcifying ossification on the left quadriceps.  She had an antalgic gait pattern with avoidance of weight bearing on the left lower extremity and her left foot was externally rotated.   She had significant weakness of the left thigh and hip musculature, which appeared to be pain inhibited and led to the altered gait pattern and inability to ascend and descend stars reciprocally.  Neurologic evaluation in September 2003 noted post-traumatic residua of incomplete left lateral femoral cutaneous syndrome (peripheral mononeuropathy/meralgia paresthetica type presentation); short leg syndrome left lower extremity with lumbosacral and sacroiliac instability and paravertebral muscle hypertonicity and pain; lateral quadriceps and possibly tensor fascia latae atrophy and hyperesthesia (excessive physical sensitivity with a non-noxious stimulus) with components of allodynia (painful sensation caused by innocuous stimuli); and alert subluxation of the left acetabular hip region.  Electrodiagnostic testing was normal without any evidence of lower extremity radiculopathy.  In December 2003 she received a series of sacroiliac joint injections.  Magnetic resonance imaging (MRI) studies of the left knee and lumbar spine were normal on 1 January 2004.  A rehabilitation therapy note in February 2004 indicated the CI was doing significantly better and 80% improved with SI injections.  

The 3 March 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of left lower extremity pain.  Physical examination showed an antalgic gait.  Flexion of the lumbar spine was 90 degrees (normal 90), extension 10 degrees (normal 30), lateral bending 50 degrees (normal 30 degrees each side), and lateral rotation 60 degrees (normal 30 degrees each side).  The CI was able to toe and heel walk and had a negative straight leg raise (to determine nerve root irritation).  Strength was 5/5 and reflexes were 2+ of the lower extremities.  She had hyperesthesia on the lateral aspect of her left thigh and she had decreased sensation over the left anterior shin as well as the sole of her left foot.  She had a full active ROM of the hip and knee and was tender to palpation over the left SI joint and over the soft tissues of the L2-L5 spinous processes as well as the paraspinals with even light touch.  There was no palpable defect within the lateral aspect of her left thigh and no leg length discrepancy.  

At the 1 August 2005 VA Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported pain in the left thigh, knee, and numbness in the lower leg and foot with a baseline of pain at 4/10 (10 being the worst pain) and walking 15 minutes increased the pain to a level of 10/10.  She reported tenderness in the left lateral quadriceps and weakness and stiffness in the left leg, which locked up once a week and the left leg gave out on her.    Physical examination showed the CI walked with a straight cane (since August 2002) with a left limp.  She was not able to walk on her toes, but was only able to walk on her heels for a short distance and tandem walk for three or four steps with cane support.  She did have an indentation in the left lateral quadriceps muscle.  The left thigh was 62 cm and the right thigh was 65 cm.  Both legs measured 39 cm from the anterior iliac crest to the inner heel.   Sensation was intact in the feet with the exception of the great toe.  Reflexes were normal and left leg strength was 3/5 against resistance.  Left hip flexion was to 90 degrees (normal 125) with pain, adduction to 25 degrees (normal 25), abduction to 45 degrees (normal 45), external rotation to 60 degrees (normal 45), and internal rotation to 40 degrees (normal 40) with pain for adduction and abduction.  There was increased pain with repetitive motions, which was minimal.  There was no increased weakness, decreased endurance, incoordination, or loss of motion with repetition.  Repetition helped lessen the pain after popping the hip joint.  Right lower extremity strength was 5/5.  Knee flexion was 120 degrees (normal 140) and extension 0 degrees (normal 0).  She had pain, which increased with repetition, in the lateral quadriceps with ROM.  There was no laxity or evidence of a meniscal tear.  The ankle ROM was normal and left foot strength was 3/5 to 4/5 with plantar flexion and dorsiflexion.  X-rays of the hips and left femur were normal with no abnormal soft tissue calcification.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain left leg condition 0%, coded 5099-5003 (arthritis, degenerative), citing no objective evidence found on multiple examinations for continuation of pain and rated as slight occasional.  The VA  also  initially rated the residuals, left quadriceps muscle tear condition 0%, coded 5314 (Group XIV-Anterior thigh group), based on the C&P examination 10 months after separation, citing slight muscle disability.  The VA increased the left lateral femoral cutaneous syndrome, residual of left quadriceps muscle tear the rating to 10%, coded 8726 (anterior crural nerve (femoral)-neuralgia), citing mild incomplete paralysis of the thigh muscle.

Panel members noted the CI sustained an injury to the left hip that resulted in a tear of the vastus lateralis muscle with a residual limp, hyperesthesia and decreased sensation distally as well as pain in the SI area.  Members first considered a rating using hip codes; however, there was no hip ankylosis (code 5250), no limitation of extension or flexion (codes 5251 and 5252), thigh impairment (code 5253), hip, flail joint (5254), or femur impairment (code 5255) in the absence of a fracture with nonunion or malunion.  Use of code 5314 was discussed since the vastus lateralis (also called the vastus externus) was the site of injury.  Furthermore, the left thigh measurement was 3 cm less than the right thigh.  The CI walked with a limp (VASRD §4.40 (functional loss)) and continued to use a cane post-separation, had tenderness to palpation overlying muscles and soft tissues of the hip, and had subjective weakness as well as weakness to resisted extension, which improved by the time of the NARSUM examination when muscle strength was normal.  Members noted the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.  While the CI did not have a penetrating wound of the muscles; nevertheless, there was a tear of the vastus lateralis and a loss of muscle substance whether from the healing of the tear or from disuse as well as loss of power manifested by difficulty walking unaided or for an extended time or distance.  Therefore, members considered the muscle condition moderate IAW VASRD §4.56 and VASRD §4.73, and no higher, warranting a 20% rating,
Members also noted that IAW VASRD §4.55 a “muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions.”  While the CI had hyperesthesia of the thigh and findings suggestive of meralgia paresthetica, an additional rating for that pain, albeit superficial, is therefore precluded.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the chronic pain left leg condition, coded 5314.  

BOARD FINDINGS:  In the matter of the chronic pain left leg condition, the panel unanimously recommends a disability rating of 20%, coded 5314 IAW VASRD IAW VASRD §4.56 and VASRD §4.73.  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	
Chronic Pain Left Leg	5314	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170019480, 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