RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-03818
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060912

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Infantryman, medically separated for “gunshot wound [GSW] through and through left calf muscle” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made. 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 - 20060802	VARD - 20070323	
Condition	Code	Rating	Condition	Code	Rating	Exam	
GSW, Left Calf Muscle	5311	10%	Residuals of GSW Left Lower Leg	5311	30%	20061116	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Left Calf Muscle GSW. According to the service treatment record and MEB narrative summary (NARSUM), the CI suffered a self-inflicted GSW to the left calf while changing the clip of his weapon during a training exercise on 15 April 2005. The entry wound was 1 cm and the exit wound was 5 X 10 cm, and X-rays revealed findings consistent with acute soft tissue trauma but no acute osseous abnormality. He underwent emergency fasciotomy of the left leg with irrigation and debridement. On 18 April 2005, he had another irrigation and debridement of a small amount of muscle, and the lateral wound was closed and the medial wound left open.     On     25 April 2005, he underwent further debridement and irrigation and a split thickness skin graft from the anterior thigh was obtained, meshed, placed and secured over the wound. On 29 April

2005, the skin graft had taken almost completely, but left ankle range of motion (ROM) was limited by gastrocnemius shortening and weakness.

During the 15 December 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported wearing a brace on the left leg. Physical examination revealed significant atrophy of the left gastrocnemius muscle and a poikilothermic (temperature changes according to the environmental temperature) left foot with normal capillary refill. There was decreased strength of the left leg, but left knee ROM was normal. At a physical therapy visit on 3 March 2006, the CI had a non-antalgic, symmetrical gait with increased pronation bilaterally in stance, but he was unsteady with a single leg stance. The scar tissue over the left leg was more pliable then at prior visits. Left ankle dorsiflexion was to 0 degrees (normal 20) and plantar flexion to 40 degrees (normal 45).

During the 29 March 2006 MEB NARSUM examination, 5 months prior to separation, the CI reported an inability to run, squat, carry heavy loads, stand for long periods of time or do his job. Physical examination showed well-healed wounds on the medial and lateral aspects of the left leg. There was a defect of soft tissue on the medial aspect of the middle of the left calf with a well-healed skin graft. Sensation was decreased distal to the wounds on the medial and lateral aspects of the left leg, but there was no evidence of a circulation disturbance in the left lower extremity. He had active left ankle extension to 10 degrees and normal flexion. By 7 April 2006, the scar tissue had matured and was pliable. Dorsiflexion of the left ankle with towel assist was to 5 degrees and plantar flexion to 45 degrees, with normal strength in all ankle muscle groups.

At the 16 November 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant left lower leg pain, rated at 3-4/10. Physical examination showed an antalgic gait, a scar (5 cm x 10 cm x 2 cm) into muscle and subcutaneous tissue over the left posterior lower leg, and partial loss of muscle group XI. Strength was decreased in the left lower leg and ankle at 4/5. Sensation was decreased to light touch in the left lower leg from the scar, dorsum foot and tops of the toes. Left ankle dorsiflexion was to 5 degrees and plantar flexion to 20 degrees, with no ROM degradation after repetition. There was no instability or pain, but there was incoordination, weakness and easy fatigability. Left leg X-rays showed extensive soft tissue injury, but no underlying bone abnormality. The final diagnoses were: history of GSW to the left lower leg with residual partial muscle group XI loss-symptomatic; residual scars secondary to GSW status post surgeries, non-tender, non-fixed; and mild incomplete paralysis of the left superficial peroneal nerve with residual loss of sensation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left calf condition 10%, coded 5311 (group XI muscle injury), citing a moderate muscle injury. The VA rated the left calf condiiton 30%, coded 5311, based on the C&P examination citing severe muscle injury with “ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation showed loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function.”

The panel first noted that IAW VASRD §4.56 (evaluation of muscle disabilities), “a through-and- through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged” and “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 PEB rated the CI’s disability 10% for a moderate muscle injury, panel members noted that the objective findings were more consistent with a moderately severe disability at 20%, which requires evidence of “loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side.” Tests of strength and endurance compared with sound side demonstrated positive evidence of impairment.        Although the VA

assigned a 30% rating for a severe muscle injury, the CI’s clinical findings at the time of separation did not appear to rise to the objective findings required for a 30% rating, or the following signs of severe muscle disability: X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. Visible or measurable atrophy. Adaptive contraction of an opposing group of muscles. Atrophy of muscle groups not  in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. Induration or atrophy of an entire muscle following simple piercing by a projectile.” Furthermore, after separation he worked as a laborer, missed no work due to his injury, denied functional impairment, and was able to perform all activities of daly living. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for left calf muscle injury, coded 5311.

BOARD FINDINGS: In the matter of the left calf muscle injury, the panel recommends a disability rating of 20%, coded 5311 IAW VASRD §§4.56, and 4.73. 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 the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Gunshot Wound Through and Through Left Calf Muscle	5311	20%	

The following documentary evidence was considered:

PD-2017-03818

AR20190010893, XXXXXXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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. 

PD-2017-03818