RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01338
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20050204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Machinist Mate, medically separated for “saphenous nerve injury” 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 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 - 20041018	VARD - 20050302	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Saphenous Nerve Injury	8727	0%	Reflex Sympathetic Dystrophy, with Residual Painful Scar, Left Knee	7804	10%	20050124	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Saphenous Nerve Injury.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s saphenous nerve injury was incurred on 7 March 2003 after she fell down a ladder and sustained an 18 cm x 4 cm laceration of the proximal one third of the left lower leg.  The wound was cleaned and closed in layers.  On 24 March 2003 the wound showed early signs of infection and on 28 March 2003 an area of necrotic tissue was debrided.  At an orthopedic clinic visit on 7 May 2003 the examiner noted a well-healed laceration with a positive Tinel’s sign (to determine nerve irritation) over the laceration at the medial joint line.  The examiner diagnosed a neuroma of the saphenous nerve.  

At a physical medicine and rehabilitation visit on 27 October 2003 the CI complained of significant pain problems present on the knee along with numbness in the distribution of the saphenous nerve on the left and some numbness and tingling on the dorsal portion of the left foot and between the toes.  Electrodiagnostic (EMG) testing was normal.  On examination, the CI had some intermittent numbness and tingling present on the left foot and in the distribution of the saphenous nerve, which may have been secondary to some intermittent swelling and edema present because of the scar injury.  The CI underwent a left leg Bier block (intravenous regional anesthesia) on 11 February 2004 and underwent excision of a left knee saphenous neuroma and scar revision on 8 April 2004.  However, pathology revealed soft tissue and a segment of unremarkable blood vessel; a nerve was not identified.  The CI was seen in the emergency room on 28 May 2004 for postoperative cellulitis and was treated with antibiotics.  

The 15 September 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of saphenous nerve paresthesias.  Physical examination showed full range of motion (ROM) of her knees.  She did have a positive Tinel’s sign superiorly and inferior to a well-healed traumatic laceration on her knee and the irritation radiated down to her foot.  Light touch sensation was intact in the first web space in the dorsal, lateral, volar, and medial aspect of her foot.  Motor strength was 5/5.  The examiner’s diagnosis was saphenous nerve injury with a continued painful neuroma of the left knee.  

During the 5 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported left knee numbness.  Physical examination showed edema of both lower extremities, tenderness about the left knee, and decreased ROM (flexion) of the left knee with tenderness. 

At the 25 January 2005 VA Compensation and Pension (C&P) general medical evaluation, 2 weeks before separation, the CI reported suffering from a left knee neuroma and a scar of the left knee and she had one episode of incapacitation for 30 days.  Physical examination showed a scar of the left medial knee that was jagged and measured about 12 cm x 1 cm with tenderness.  There was keloid formation and hyperpigmentation of less than six square inches and limitation of motion.  There was no evidence of laxity or meniscal tear.  There was severe tenderness on the medial knee near the scar.  The ROM of the left knee was 0-80 degrees (normal 0-140) with pain at 80 degrees.  

The 23 June 2005 VA C&P neurological disorders evaluation, 5 months after separation, noted complaints of knee and scar pain with a radiating electrical pulse type of pain to the scar site one time every hour that lasted about a second.  Physical examination showed the CI walked with an unsteady gait, significantly favoring her left leg.  She did not bend the knee fully, but did not use an assistive device.  There was a 13 cm x 1 cm irregular shaped well-healed scar, which was mildly tender.  The CI reported numbness to a freely moveable scar and surrounding tissue.  The left knee and left scar area were without redness, swelling, or heat.  ROM of the left knee was 0-130 degrees with significant pain at 122 degrees.  There was no change on repetition.  There was no left lower extremity muscle atrophy and hair distribution was normal.  The examiner noted she had small nerve fibers to the surrounding area that would not be detected on EMG, but could cause pain to the surrounding area.  The examiner’s diagnosis was left lower extremity trauma with localized neuritis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded 8727 (neuralgia of the internal saphenous nerve).  The VA rated the left knee condition 10%, coded 7804 (scars, unstable or painful), based on the C&P examination 2 weeks before separation, citing a painful scar.   Later, the VA rated the left knee condition 10%, coded 7804-5260 (scar(s), unstable or painful-leg, limitation of flexion of), based on the VA C&P examination 5 months after separation, citing the evaluation of 10% was continued based on a superficial scar that was painful on examination.  
Panel members noted code 8727 (internal saphenous nerve, paralysis of) has a maximum rating of 10% for severe to complete paralysis.  Therefore, the PEB rating of 0% using code 8727 for neuralgia was consistent with a mild to moderate condition especially in the absence of positive electrophysiologic findings and the absence of pathology to support the clinical impression of a saphenous nerve neuroma.  Members then considered whether a rating using a scar code offered a higher rating since the sensitivity and pain was in the area of the traumatically induced laceration that resulted in scarring.  There was also a positive Tinel’s test superior and inferior to the well-healed traumatic laceration.  Code 7804 for a 10% rating requires one or two scars that are unstable or painful, which is applicable in this case.  Members noted that several examinations addressed knee pain; however, the knee pain is not in the scope of review, although it seems the knee pain emanated from either the saphenous nerve injury or the scar or both; and no knee code is applicable to use for rating purposes.  The panel majority agreed that a higher rating of 10% for the saphenous nerve injury using code 8727-7804 was appropriate in this case.  The minority member voiced concern about the scar being in the scope of review.   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the saphenous nerve injury condition, coded 8727-7804.  

BOARD FINDINGS:  In the matter of the saphenous nerve injury, the panel majority recommends a disability rating of 10%, coded 8727-7804 IAW VASRD §4.124a and VASRD §4.118.  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 the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Saphenous Nerve Injury	8727-7804	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161001, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
	 (b) PDBR ltr dtd 11 Mar 18 ICO XXXXXXXXXXXXXXXXXX 
	 (c) PDBR ltr dtd 11 Mar 18 ICO XXXXXXXXXXXXXXXXXX 
	 (d) PDBR ltr dtd 12 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 11 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 12 Mar 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.       

     b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 50 percent rating (increased from 10 percent) effective date of discharge.  

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
 
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.