RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01534
BRANCH OF SERVICE:  ArmY 	SEPARATION DATE: 20040624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “chronic pain and numbness right leg, status post gunshot wound right thigh and left knee” with a disability rating of 10%.   

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 -20040421	VARD – 20050620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain And Numbness Right Leg…	5099-5003	10%	Gunshot Wound Right Thigh	5315	30%	STRs	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Leg Pain and Numbness.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic right leg pain and numbness began in April 2003 after sustaining a gunshot wound to the right thigh and left knee area.  At a follow-up appointment on 24 July 2003, following surgery and debridement of the area, the CI complained of numbness of the right medial thigh area radiating into the right groin when walking.  A 12 August 2003 bone scan showed “moderately extensive soft tissue uptake of the right tissues of the right mid-thigh that represents more likely soft tissue calcification.”  

During the 4 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported right leg numbness due to the gunshot wound and pain that awakened him at night.  Physical examination showed a 6-cm x 3-cm scar at the right medial thigh, a 1.5-cm x 1-cm scar at the right lateral thigh, 3 parallel scars measuring 2.5 cm at the left proximal/medial patella area and a 3-cm x 2-cm scar proximal to the left patella.  The examiner documented “gunshot wound right leg” noting the entrance wound was to the lateral thigh area, and the exit wound to the medial thigh area near the saphenous vein, where the CI experienced numbness to just below the knee cap.  

The 2 April 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of right leg pain and numbness with pain radiating down into the right groin and foot.   The CI was unable to effectively run and could only walk half a mile due to pain.  Physical examination showed a dorsal/mid-right thigh entrance wound and medial/mid-right thigh exit wound.  There was a 4-cm area of sensory numbness from the medial right thigh wound to the medial knee, but no motor or circulatory impairment of the right lower extremity.  Right hip range of motion (ROM), in degrees, was: flexion to 90 (normal 125), abduction to 30 (normal 45) and external rotation to 45 (normal).  Right knee flexion was from 0 to 115 degrees (normal 0-140).  

At the 26 May 2005 VA Compensation and Pension (C&P) general examination, 11 months after separation, the CI reported right thigh pain rated at 7/10, which worsened with relaxation and was somewhat relieved with movement.  He could walk a quarter of a mile and denied problems with standing or sitting.  Physical examination showed pain to palpation of the right thigh scar with normal strength in all extremities.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right leg pain and numbness condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing “without limitation of motion” and the US Army Physical Disability Agency pain policy.  The VA rated the right thigh gunshot wound condition 30%, coded 5315 (group XV function), based on the C&P examination 11 months after separation, citing “severe muscle disability, severe impairment of function and loss of deep fascia or muscle substance, or soft flabby muscles in the wound area.” Members noted the CI’s right thigh gunshot entrance and exit wounds were debrided, and although the criterion for moderately severe muscle disability based on the type of wound (a through-and-through or deep penetrating wound due to high velocity missile with debridement) was met, there was minimally decreased strength or endurance demonstrative of moderately severe muscle impairment for a 30% rating under 5315.  Under diagnostic code 5099-5003, the CI only met criteria for a rating of 10% due to subjective evidence of pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic right leg pain and numbness condition.  

BOARD FINDINGS:  In the matter of the chronic right leg pain and numbness condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161018, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001830, 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