RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03243
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20071001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Chemical Operations Specialist, medically separated for “left leg pain” and “dysfunction of the right thumb,” rated 10% and 0%, respectively, with a combined 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 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 - 20070503	VARD - 20081119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Leg Pain 	5271	10%	Limited Range Of Motion, Left Ankle, Status Post Gunshot Wound, Left Lower Leg	5271	0%	20080714	
Dysfunction Of The Right Thumb 	5228	0%	Muscle Weakness, Status Post, Gunshot Wound, Right Thumb	5307-5308	NSC	20080714	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Left Leg Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left leg condition began in February 2006 after being shot outside a nightclub in the upper left thigh.  Surgery was performed on the left leg and an artery was taken from the right leg and placed into left leg.  The injury resulted in the CI having pain with walking any distance affecting his left foot and ankle, along with numbness of the left foot and marked left foot drop with under curling of the great toe.  At the 7 September 2006 physical therapy (PT) evaluation, 13 months before separation, the CI reported 8/10 left leg pain.  Physical examination showed left ankle with 45 degrees (normal) of plantar flexion and 10 degrees (20 normal) of dorsiflexion and pain did not limit the range of motion.  Active range of motion (ROM) of the left great toe was 0 degrees flexion and 0 degrees extension.  The right great toe was 35 degrees flexion and 75 degrees extension.  

The 19 September 2006 MEB NARSUM examination, 13 months prior to separation, noted complaints of chronic anterior left leg numbness and tingling of the anterior leg and pain in the anterior left thigh.  Physical examination showed a mild to moderate antalgic gait.  The 17 November 2006 MEB NARSUM addendum examination, 11 months prior to separation, noted complaints of chronic anterior left leg pain with some numbness and tingling and foot dysfunction.  Physical examination showed the CI had a mild to moderate antalgic gait.  Left ankle had decreased ROM of passive movement mostly involving plantar flexion and paresthesia of the anterior ankle.  The left foot had a normal arch, left plantar soft tissue tenderness, and decreased flexion of all five left toes.  Exam of left foot was consistent with "foot drop.  The examiner concluded that there was obvious neurologic damage of his left lower extremity due to his injury either directly from nerve disruption from the bullet or from compartment syndrome damage.  

At the 14 July 2008 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported 7/10 left leg pain, loss of strength, and easy fatigability worse with activity.  Physical examination showed no muscle group involved.  Palpation of the muscle did not reveal loss of deep fascia, loss of muscle substance, or impairment of muscle tone.  There was a left leg wound present with no intermuscular scarring, adhesion to the bone, or signs of lowered endurance and impaired coordination.  There were no muscle groups involved; therefore muscle strength was not graded.  There was no muscle injury or herniation.  Examination of the left femur, tibia, and fibula were all within normal limits.  The left ankle had no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement.  Examination of the ankles did not reveal dorsiflexion deformity, plantar flexion deformity, inversion deformity, or eversion deformity.  The ROM of the left ankle joint was dorsiflexion 20 degrees and plantar flexion 45 degrees.  On the left, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  There was no indication of malunion of the astralgus on the left.  The left knee showed no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement.  The ROM of the left knee joint was flexion 140 degrees (normal) and extension 0 degree (normal).  On the left, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Tests for stability of the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments were all within normal limits.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5271 (ankle, limited motion of), citing limitation of motion.  The VA rated the left ankle condition 0%, also coded 5271, based on the C&P examination, citing ROM within normal limits.  The panel noted that although the initial injury was to the CI’s thigh, there was underlying artery and nerve damage that affected his left foot.  The panel agreed that there was left foot decreased ROM at the moderate level to justify a 10% rating under 5271 as adjudicated by the PEB.  The ROM was not to the level of “marked” to justify the higher 20 rating.  There was a history of foot weakness supporting a 10% rating under 5277 (weak foot, bilateral); however it is not a separate condition which could be rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  There was no evidence of claw foot (5278), or acquired flatfoot (5276), and no tarsal or metatarsal bone malunion or nonunion (5283).  There was no evidence of other foot injuries (5284) to support a moderately severe 20% rating under the respective diagnostic code (big toe).  There was no other VASRD §4.71a route to a higher rating under any applicable code for the foot.  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 left leg pain condition.  

Dysfunction of the Right Thumb.  According to the STR and MEB NARSUM, the CI’s right thumb condition began in February 2006 after being shot outside a nightclub with loss of a portion of bone.  At a 17 May 2006 primary care evaluation the CI reported no specific thumb complaints.  Right thumb physical examination showed decreased ROM in all planes.  At the 7 September 2006 PT evaluation, 13 months before separation, the CI reported thumb pain.  Bilateral thumb ROM showed carpal metacarpal joint (CMC) flexion was 15 degrees right and 15 degrees left.  CMC extension was 55 degrees right and 70 degrees left.  CMC adduction to abduction was 0 to 45 degrees right and 0 to 60 degrees left.  Metacarpal phalange joint (MCP) extension to flexion was 0 to 30 degrees right and 0 to 80 degrees left.  Interphalangeal (IP) joint extension to flexion was 0 to 10 degrees right and 0 to 90 degrees left.  The reason for the right limitation was bony block joint end feel.  Pain did not limit ROM in all motions.  

The 17 November 2006 MEB NARSUM addendum examination, 11 months prior to separation, noted complaints of right thumb pain.  Physical examination showed the right thumb had a severely restricted ROM of the MCP joint of 20 degrees and IP joint of 5 degrees.  Abduction and adduction of the thumb were normal.  Muscle grip of the hand was good; however the right thumb was unable to fully engage a squeezed object.  Paresthesia of the entire span of the thumb tip was present.  At the 14 July 2008 VA C&P examination, 9 months after separation, the CI reported right thumb pain up to 6/10 with physical activity, stress, writing, or gripping.  Physical examination showed the right hand dominant CI could tie his shoelaces, fasten buttons, and pick up a piece of paper and tear it, all without difficulty.  Hand dexterity showed the right hand fingertips could approximate the proximal transverse crease of the palm.  With the thumb attempting to oppose the fingers, the measurement between the tip of the right thumb and the tip of the fingers was 0 cm for the index finger, long finger, ring finger, and little finger.  His right hand strength was within normal limits.  The ROM of the right and left thumbs was radial abduction 70 degrees; palmar abduction 70 degrees; MCP flexion 60 degrees, IP flexion 60 degrees, and the opposition of the thumbs were within normal limits.  On the right, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right thumb condition 0%, coded 5228 (thumb, limitation of motion), citing no evidence that the thumb cannot oppose all the fingers.  The VA rated the right thumb condition not service connected, coded 5307-5308 (thumb, flexion and extension) based on the C&P examination, citing no evidence of muscle herniation, tendon damage, bone damage, joint damage, or nerve damage.  There was no ankylosis or thumb limitation of motion to support a rating under the VASRD diagnostic codes for limitation of motion (5224 or 5228).  There was no evidence of muscle groups VII, VIII, or IX dysfunction to support a rating (5307, 5308, and 5309).  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 thumb condition.  

BOARD FINDINGS:  In the matter of the left leg condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right thumb condition and IAW VASRD §4.71a, the panel 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 20170329, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20180005913, 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