RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04197
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Armor Crewman, medically separated for “chronic pain in right wrist, right hip and bilateral knees” 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 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 - 20061204	VARD - 20071031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in Right Wrist, Right Hip and Bilateral Knees	5099-5003	10%	Residuals, Fracture, Right Distal Radius	5212	10%	20070718	
			Residuals, Fracture Left Lateral Condyle	5255	10%	20070718	
			Degenerative Changes, Right Knee, Residuals of Fracture, Right Proximal Femur	5255	10%	20070718	
			Pubic Symphysis Diastasis, Internal Fixation	5299-5298	0%	20070718	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Pain in the Right Wrist, Right Hip and Bilateral Knees.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right wrist, right hip, and bilateral knee pain began on 21 July 2005 after a motorcycle accident.  The evidence for the conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Right Wrist Pain.  Wrist and forearm X-rays after the motorcycle accident in July 2005 showed:  a fracture of the distal radius with considerable dorsal displacement of the carpus (bones of the wrist) along with the fractured distal radial fragment; and a fracture of the shaft of the distal ulna and displaced fracture of the ulnar styloid process.  Despite several attempts to reduce the distal radius fracture, a fragment appeared to remain displaced, and the CI subsequently underwent an open reduction and internal fixation (ORIF) on 22 July 2005, with postoperative X-rays showing fragments in anatomic alignment with a plate and screw fixation of the distal radius.  A fracture through the base of the ulnar styloid was noted, with minimal displacement of the distal fragment, and a tiny bony fragment was also seen situated along the medial aspect of the distal ulna unchanged from the preoperative study. On 12 April 2006, X-rays showed good position and alignment of the radial fracture and hardware with a normal progression of bone union without evidence of complications.

At the 2 February 2006 MEB NARSUM examination, 11 months prior to separation, the CI complained of continued right wrist pain, and the examiner noted a healed scar and minimal diffuse tenderness about the wrist.  Flexion was to approximately 25 degrees (normal 80) and extension to approximately 10 degrees (normal 70).  On the same day, X-rays showed the distal radial and ulnar styloid fractures with no hardware complications or position changes from a previous study.  During the 6 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months before separation, the CI reported pain with wrist movement. Physical examination revealed no tenderness, but flexion, extension, and radial/ulnar deviation were decreased (not quantified), with popping and pain elicited by ulna deviation and extension; hand grip strength was normal.  The 20 November 2006 MEB NARSUM addendum examination, 2 months prior to separation, noted complaints of right wrist pain, stiffness, and weakness.  Physical examination showed wrist ROM limited by pain, with flexion to 53 degrees, extension to 35 degrees, radial deviation to 20 degrees (normal) , and ulnar deviation to 28 degrees (normal 45).  The examiner noted that overall he “moved well and did not demonstrate any major disability.”  Strength was 5/5 and grossly symmetric, except for right hand grip strength, which was approximately 60% of left hand grip strength.  

At the 18 July 2007 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported right wrist pain with weakness and lack of endurance.  Wrist ROM measurements, in degrees, showed dorsiflexion to 35, palmar flexion to 70, radial deviation to 20, and ulnar deviation to 35.  There was endpoint pain in all planes except for radial deviation, but no pain during motion or loss of motion with repetition.  There was full ROM of the hands and fingers without pain or difficulty. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled right wrist, right hip, and bilateral knee conditions 10%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy. The VA rated the right wrist condition 10%, coded 5212 (radius, impairment of).  Panel members first agreed that the chronic right wrist pain was reasonably justified as separately unfitting based on evidence of functional limitations.  When considering its rating recommendation, the panel noted the right wrist was limited by pain at the MEB NARSUM addendum examination, which was more proximate to separation than the C&P examination, and thus adjudged that a 10% rating was warranted under code 5099-5003.  Panel members considered other VASRD wrist and analogous codes but all were less applicable and/or not advantageous for rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right wrist condition, coded 5099-5003.  

Right Hip Pain.  After the motorcycle accident, X-rays showed diastases (separations) of the symphysis pubis and right sacroiliac (SI) joint, no hip fractures or dislocations, and a right femur mid-shaft comminuted fracture.  A CT scan of the abdomen and pelvis showed a small amount of gas in the right SI joint, which was slightly widened when compared to the left with a maximal separation of 5 mm.   Additionally, the pubic symphysis was separated 2.3 cm at its maximum.  On 22 July 2005, the CI underwent an ORIF of the femur fracture with intramedullary nail placement.  Postoperatively, he was febrile and anemic and was treated with antibiotics and transfused with two units of packed red blood cells.  On 27 July 2005, the pelvic fracture was surgically reduced with a volar plate fixation and a right leg rotational deformity was reduced with revision of the distal interlock.  Post-operative X-rays in November 2005 and February 2006 showed femur fracture healing status post internal fixation with the intramedullary rod and cortical screws, and the symphysis pubis was fixated with a plate and cortical screws; there were no hardware complications.  

The MEB NARSUM examiner noted complaints of continued right hip pain and found diffuse right hip tenderness, but no pain in the pubic symphysis region.  During the MEB examination, the CI reported the pelvis plate and rod in the right leg, and physical findings showed hip pain elicited by adduction.  The MEB NARSUM addendum examiner documented CI reports of intermittent right hip pain, and found no hip deformity or focal tenderness to palpation.  Hip ROM was tested in the supine position, and limitation “seemed to be” primarily mechanical, with measurements, in degrees, showing:  flexion to 120 (normal 125), extension to -5 (normal 20), adduction 25 (normal), and abduction to 15 (normal 45), and pain at the extreme of adduction.  Trendelenburg testing (to determine hip weakness in the abductor muscles: gluteus medius and gluteus minimus) was negative and Faber testing (to determine hip or sacroiliac pathology) produced pain.  At the C&P examination, the CI reported pain in the right femur and right pelvis area with prolonged walking or with cold exposure.  Physical examination showed full hip ROM without pain or difficulty.
  
The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bundled right wrist, right hip and bilateral knee conditions 10%.  The VA rated the right hip pain as “degenerative changes, right knee, residuals of fracture, right proximal femur” 10%, coded 5255  (femur, impairment of: malunion of: with slight knee or hip disability), based on the C&P examination, citing evidence of painful knee motion.  The VA also rated the pubic symphysis condition 0%, analogously coded 5299-5298 (coccyx, removal of: without painful residuals), citing no objective evidence of functional disability of the pelvis structure.  Panel members first agreed that the chronic right hip pain was reasonably justified as separately unfitting based on evidence of functional limitations.  When considering its rating recommendation, the panel noted that the right hip pain was related to fractures of the right femur and the pubic diastasis, both of which were surgically repaired, and thus appropriately coded 5255.  Panel members considered other VASRD hip and analogous codes, but all were less applicable and/or not advantageous for rating.  While there was no significant hip disability to warrant a rating higher than 0%, the question of whether the right knee had a mild disability to warrant a 10% was deferred to the panel discussion below.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right hip condition, coded 5255.  

Chronic Bilateral Knee Pain.  Following the motorcycle accident, the CI was noted to have a large soft tissue deformity over the left knee, which on further exploration revealed an open injury.  Knee X-rays demonstrated an essentially normal left knee, with possible gas in the soft tissues in a suprapatellar position; and an unremarkable right knee, but a comminuted fracture of the right femur as discussed above.  During the orthopedic consultation, the CI complained of right thigh and left knee pain.  The provider noted the left lower extremity had a soft tissue deficit over the patella anteriorly, and the wound was explored and copiously irrigated with normal saline and found to communicate with the knee joint as it progressed medially around the patella. Examination of the right lower extremity showed no knee effusion.  In the operating room on 22 July 2005, excision of traumatic wounds of the left knee was performed, and an arthrotomy through a medial parapatellar approach into the knee was then completed.  Devitalized skin as well as subcutaneous tissue were removed in combination with through irrigation and exploration through the arthrotomy.  Closure of the capsule, subcutaneous tissue and skin were then accomplished.  The hospital discharge summary indicated a left femoral condyle Hoffa fracture (intra-articular supracondylar distal femoral fracture), although there was no X-ray report in the STR.  On 17 November 2005, left knee X-rays showed a cortical infarction in the medial femoral condyle best seen in the sunrise view.  On 19 April 2006, X-rays demonstrated early degenerative changes at the medial compartment with no acute abnormality, and an MRI the same day, revealed a moderate joint effusion outlining the patellar cartilage with severe damage into the medial femoral condyle and an osteochondral defect on the mid portion of the weight bearing part of the condyle.  Cortical disruption was evident and the overlying cartilage was irregular.  The medial meniscus appeared intact and the tibial plateau and cartilage were normal.  The lateral compartment as well as cruciate and collateral ligaments were also intact.  

The MEB NARSUM examination noted CI complaints of bilateral knee pain, and physical findings showed multiple, healed lower extremities scars, but no deformities or swelling.  There was left peripatellar tenderness, however, all tests were negative in both knees for instability.  Bilateral knee ROM was 0-125 degrees (normal 0-140).  During the MEB examination, the CI reported knee pain with locking up and giving out.  Physical examination of both knees revealed tenderness medially and laterally and in the subpatellar areas, but no edema or erythema.  There was full ROM with audible popping during motion, but “no pain was elicited.” The MEB NARSUM addendum examination noted complaints of knee pain, and physical findings revealed normal appearing knees with several traumatic postsurgical scars, but no swelling.  The examiner noted that “knee pain occurred with almost every movement and with moderate palpation in multiple areas, which was nonspecific,” and that “limitation seemed to be primarily by pain,” with active bilateral flexion from 0-130 degrees (normal 140).  There was no laxity, instability, or patellofemoral dysfunction, but McMurray’s testing (to determine a meniscal tear) was positive on the right.  At the C&P examination, the CI reported knee pain with weakness, stiffness, instability, locking and lack of endurance.  He utilized a cane and had a brace for the right knee.  Physical examination of the knees showed ROM from 0-120 degrees bilaterally and no limitation of motion with repetition.  McMurray’s, Lachman’s, and drawer tests were normal, and there was no pain, weakness, or tenderness noted.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled right wrist, right hip, and bilateral knee conditions 10%.  The VA rated the “residuals, fracture, left lateral condyle” 10%, coded 5255, based on the C&P examination, citing a slight knee disability with no hip disability.  As noted above, the VA also rated “degenerative changes, right knee, residuals of fracture, right proximal femur” 10%, coded 5255, citing evidence of painful knee motion.  Panel members first agreed that the left and right knee conditions were reasonably justified as separately unfitting based on evidence of functional limitations.  When considering its rating recommendations, the panel deliberated over the MEB NARSUM addendum examiner’s statement that “limitation seemed to be due to pain.” The panel majority questioned the extent of the CI’s knee pain because it was noted to occur with almost every movement and “seemed” to cause limitation.  There was also no pain recorded at the VA examination, and thus the panel majority adjudged that there was insufficient evidence of painful motion with functional loss to support a rating higher than 0% for either knee.   While the fractures of the right femur fracture and left femoral condyle could support ratings for knee impairment related to long bone conditions under code 5255, panel majority felt that neither knee rose to the level of a slight disability to warrant a 10% rating.  Panel members considered other VASRD knee and analogous codes, but all were less applicable and/or not advantageous for rating. Therefore, the panel majority determined IAW VASRD §4.71a that there was no rating higher than 0% for either knee.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for each knee condition, coded 5099-5003. 

BOARD FINDINGS:  In the matter of the right wrist condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right hip condition, the panel recommends a disability rating of 0%, coded 5255 IAW VASRD §4.71a.  In the matter of the left and right knee conditions, the panel majority recommends disability ratings of 0% each, coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  As the proposed new combined disability ratings result in no change to the combined disability rating previously assigned, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Minority Opinion.  The minority voter recommends a rating of 10% for the right knee pain and a 10% rating for the left knee pain.  The CI was involved in an accident, which resulted in a right femur fracture and injuries to left knee including the skin, soft tissue, and left femoral condyle (Hoffa fracture).  To treat the right femur fracture, a rod was placed into the femur through the right distal femur, which is at the upper part of the right knee.  The fact that the CI had pain in the right knee can be attributed to both the injury sustained to the right femur during the accident and the subsequent surgery.  The left knee sustained injuries to the skin, soft tissues, and femoral condyle, which was confirmed by X-rays using a sunrise view that showed a cortical infarction.  Therefore, the left knee also was painful, which could be attributed to the injuries sustained during the accident as well as to the surgical exploration of the left knee and the Hoffa fracture.  While the panel majority felt a rating higher than 0% for either knee was not possible based on the NARSUM addendum examiner’s use of the phrase “limitation seemed to be due to pain,” and no pain being in evidence at the VA examination, 6 months after separation, the minority voter is reasonably assured there was painful motion in each knee sufficient to warrant a 10% rating for each at the time of separation, especially since the NARSUM addendum examiner noted knee pain occurred with almost every movement.  Furthermore, that view is supported by the incontrovertible fact that surgery was performed in the area of both the right knee and left knee.  When the NARSUM addendum examiner noted the “limitation seemed to be due to pain,” he could have also indicated it also may have been due to a mechanical basis secondary to scarring from either the injuries and/or the subsequent surgical procedures.  Therefore, the minority voter recommends a 10% rating using code 5099-5003 for each knee based on painful motion IAW VASRD §§4.59 (painful motion), 4.40 (functional loss), and 4.45 (the joints).  Although there was no painful motion at the VA examination, the NARSUM addendum examination carried higher probative value as it was closer to separation (2 months prior) than the VA examination, and thereby again justified a 10% rating for each knee, especially since the CI used a cane and had a brace on the right knee at the VA examination indicative of residual disability from the accident and the surgical procedures.

The minority voter also notes that code 5255 could be used for rating either knee since there were fractures of both the right and left femurs.  While the fractures presumably healed at the time of separation, there were no X-rays immediately proximate to separation to confirm the exact state of healing.  Therefore, since the NARSUM addendum examination noted painful motion of the knees, a 10% rating for each knee using code 5255 for a slight disability is reasonable, but because painful motion was also clearly evident, analogous code 5099-5003 is preferable to code 5255.  Because there was no limitation of motion to support a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) or a history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), knee ankylosis (5256), or knee impairment ((5257), there was no higher rating than 10% for either knee.  The position of the minority voter is additionally supported by the VASRD §§4.6 (evaluation of evidence affecting the probative value), 4.7 (higher of two evaluations will be assigned) and 4.3 (resolution of reasonable in favor of the claimant).  Therefore, the minority voter recommends the ROP be modified to read:

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition, coded 5099-5003, and a disability rating of 10% for the left knee condition, coded 5099-5003.   

BOARD FINDINGS:  In the matter of the right wrist condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right hip condition, the panel recommends a disability rating of 0%, coded 5255 IAW VASRD §4.71a.  In the matter of the right knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.   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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Wrist Pain	5099-5003	10%	
Chronic Right Hip Pain	5255	0%	
Chronic Right Knee Pain	5099-5003	10%	
Chronic Left Knee Pain	5099-5003	10%	
COMBINED w/BLF	30%	

AR20200000658, XXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX:

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.