RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00815
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O1, Military Police, medically separated for “right leg pain, status post right tibia/fibular fracture” with a disability rating of 10%.  

CI CONTENTION:  The VA rated higher for her back condition.  Review requested for conditions not found unfit by the Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20050504	VARD – 20060323 & 20060608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Leg Pain Status Post Tibia/Fibular Fracture	5099-5003	10%	Status Post Fracture Right Tibia and Fibula	5299-5262	10%	20041116	
Left Knee ACL Reconstruction	Not Unfitting	S/P Left Knee ACL Reconstruction Associated with S/P Fracture Right Tibia/Fibula	5299-5261	10%	20041116	
Closed Head Injury With Cognitive Disorder	Not Unfitting	Residual Head Injury	8045-9403	10%	20041116	
Functional Heart Murmur	Not Unfitting	No VA Exam in Evidence	
PTSD	Not Unfitting	Depressive Disorder	9434	NSC	20041116	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY   

Right Leg Pain Status Post Tibia/Fibular Fracture.   According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained an open right tibia and fibula fracture with laceration of the medial gastrocnemius muscle in a single vehicle (HMMWV) accident on 20 July 2003.  In late July 2003, the CI underwent a revision of her external fixator.  Despite post-fixator physical therapy, the CI was unable to tolerate impact activities.  

The 20 May 2004 MEB NARSUM examination, 12 months prior to separation, noted complaints of pain in her right leg at the fracture site along with knee pain.  The CI reported she was unable to tolerate the pain from impact of fast walking, jogging, or running.  Physical examination showed tenderness about the proximal third of her right tibia in the area of the fracture.  There was negative patellar grind; however, the CI did complain of pain in the peri-patellar region of her knee.  The range of motion (ROM) of her knees was 0 degrees extension (0 normal) and 135 degrees flexion bilaterally (140 normal).  Ankle ROM was 20 degrees dorsiflexion (normal) to 35 degrees plantar flexion (normal 45) bilaterally.  

At the 21 July 2004 PT consult the CI reported she was doing therapy every day.  She had tried using the elliptical trainer but her leg became very fatigued.  On examination, ROM was noted to be within normal limits at the hip, knee, and ankle.  Gait was antalgic. X-rays on 13 September 2004 showed a healing proximal tibial fracture with good alignment.  Soft tissues were unremarkable.  Right knee ROM measurements dated 21 October 2004 showed flexion of 127 degrees and 0 degrees extension after repetition.  The examiner noted the knee was limited due to stiffness.  Right ankle ROM was dorsiflexion of 2 degrees and plantar flexion of 64 degrees after repetition.  Ankle ROM was also limited due to stiffness.  

During the 31 March and 1 April 2005 MEB examinations (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported frequent leg pain and that her right leg was shorter than her left.  Physical examination showed right ankle ROM of 10 degrees dorsiflexion and 40 degrees plantar flexion.  Dorsiflexion strength was 4+/5.  Decreased sensation of the anterior tibia was noted.  At the 1 April 2005 addendum the CI reported no change in right leg pain which was present 50-75% of the time with some sleep disturbance.  Right ankle ROM was 10 degrees dorsiflexion and 40 degrees plantar flexion.  There was 4+/5 decreased strength in the right ankle dorsiflexion with symmetric and full plantar flexion and toe stand capability.  There was decreased sensation over the right anterior tibia and decreased right leg length of 1/2 cm per radiology report.  

At the 26 January 2006 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported constant right leg and knee pain.  Physical examination showed an abnormal gait, with a limp favoring the right leg.  Leg length was 84 cm on both the right and left leg.  There were no signs of edema, effusion, weakness, tenderness, redness, abnormal movement, or guarding of movement.  ROM of the right knee was 135 degrees flexion and 0 degrees extension with pain on flexion.  The examiner was unable to make a determination without resorting to speculation whether pain, fatigue, weakness, lack of endurance, and incoordination additionally limited the joint function.  The right ankle ROM was 20 degrees dorsiflexion and 45 degrees plantar flexion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right leg pain status post tibia/fibula fracture 10%, coded 5099-5003 (analogous to arthritis, degenerative), citing application of the US Army Physical Disability Agency pain policy.  The VA also rated the status post fracture right tibia and fibula condition 10%, coded 5299-5262, (analogous to tibia and fibula, impairment of), based on the C&P examination, citing mal-union of the tibia and fibula with slight knee or ankle disability.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no history or evidence 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 those codes.  There was no evidence of moderate knee or ankle disability to support a 20% rating under the 5262 code (tibia and fibula, impairment of).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 right leg tibia/fibula fracture.  

Contended PEB Conditions:  Left Knee ACL Reconstruction (EPTS), Closed Head Injury With Cognitive Disorder, Functional Heart Murmur, and PTSD.  The PEB did not adjudicate the conditions the MEB determined to be medically acceptable.  None of these conditions were profiled.  The commander’s statement addressed the fracture and traumatic brain injury.  The commander stated the CI would be capable of working within the scope of her MOS as a community deputy provost marshal or as a public affairs officer due to her outstanding communication skills.  The commander went on to say “she does not appear to have lost any intelligence or cognitive abilities”.  A head CT revealed no intracranial abnormality.  A neurology consult stated no further neurologic work up or follow required.  The STR contained no treatment records related to the left knee, functional heart murmur, or treatment related to PTSD.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded the preponderance of the evidence did not favor a recommendation of additional unfitting conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right leg condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left knee, closed head injury, heart murmur, and PTSD, the panel recommends no change from the PEB determinations.  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 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180004913, 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