RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXX	CASE: PD-2021-00055
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20050504

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Engineman, medically separated for “right knee pain related to healed patellar fracture and popliteus tendonitis,” “pain in left foot,” “multisystem trauma from a single motor vehicle accident,” “right femur fracture, status post ORIF [open reduction and internal fixation] with IMR [intramedullary rod]-stable,” “right hip pain-resolved with hardware removal,” “bilateral metatarsal fractures,” and “low back pain,” with a combined disability rating of 0%.

CI CONTENTION: The extent of his injuries was worse than what was documented. 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 - 20050331	VARD - 20061127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	-	0%	Traumatic Arthritis…Right Knee	5003	0%	20060509	
Right Femur Fracture	-	0%	Right Hip Strain, Old Healed Femur Fracture	5253	10%	20060509	
Right Hip Pain	-	0%					
Pain in Left Foot	-	0%	Old Healed Foot Fractures with Residual Tenderness…Left Foot	5284	0%		
Bilateral Metatarsal Fractures	-	0%					
			Old Healed Foot Fractures with Residual
Tenderness…Right Foot	5284	0%		
Multisystem Trauma	-	0%	No VA Placement	
Low Back Pain	-	0%	Degenerative Disc L5, Lumbar Spine	5010	10%	20061024	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

Controlled by: DAF Controlled by: SAF/MRBD
CUI Categories: SP-MIL/SP-PRVCY Limited Dissemination Control: N/A POC: SAF.MRBD.Workflow@us.af.mil

ANALYSIS SUMMARY:

The PEB combined the right knee pain, right femur fracture, right hip pain, left foot pain, bilateral metatarsal fractures, multisystem trauma, and low back pain under a single service disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4). This approach by the PEB reflected its judgment that the constellation of conditions was unfitting, but that none of the conditions were individually unfitting. The panel does not recommend separate disability codes and ratings in this circumstance unless a preponderance of evidence demonstrates that a condition was unfitting at separation. The evidence for each condition is presented below with attendant recommendations regarding separate unfitness and rating if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was involved in a motor vehicle accident (MVA) on 22 June 2003. He sustained multisystem trauma with right pulmonary, chest wall and abdominal contusions; fractures of the first left rib, right femur (comminuted), right patella, and bilateral metatarsals; and multiple extremity lacerations to include the left extensor hallucis longus (EHL) tendon. After life threatening injuries were ruled out, he underwent right femur ORIF surgery with IMR placement. At that time, an anterolateral right knee and an upper leg laceration were also cleaned and repaired. The CI was then transferred to a second medical treatment facility and underwent primary repair of the left EHL tendon as well as closed reduction and casting of the bilateral metatarsal fractures. After discharge he was followed by orthopedics, pain management, and physical therapy (PT).

The initial 25 July 2003 limited duty (LIMDU) medical board report listed right femur, right patellar, and bilateral metatarsal fractures as diagnoses; and “wheel-chair bound” with no shipboard duty, deployment, or weight bearing on the right leg as limitations. On 15 April 2004, 13 months before separation, the LIMDU period was extended for 8 months and the list of diagnoses included: multisystem trauma, right femur fracture, right hip pain secondary to symptomatic interlocking screw, bilateral metatarsal fractures, left foot pain foot secondary to subluxed first MT bone from poorly healed fracture, healed right patellar and first rib fractures, and status post left EHL tendon repair. The LIMDU board noted the right hip and the left foot were the CI’s primary sources of pain. At that time, orthopedics planned to remove symptomatic interlocking screws of the right femur and discussed fusion of the left metatarsal bone if it remained symptomatic. During the examination, the CI reported being able to walk for only 10 minutes without pain and tolerated swimming for half a mile, 2-3 times a week. He was able to walk up three flights of stairs with minimal difficulty, but unable to run/jog or perform impact activities. On examination, he walked without assistance and had a normal gait. Except for no longer needing a wheel chair, his limitations remained the same.

According to the 9 December 2004 MEB NARSUM, 5 months prior to separation, the CI had made significant progress in his recovery. He was ambulating without assistance and being treated with Neurontin (nerve medication), Elavil (antidepressant used for chronic pain), Mobic (anti- inflammatory medication), and oxycodone (narcotic) by pain management. His primary sources of pain were from the right knee, left foot, and non-radiating back pain. The examiner noted the right hip pain had resolved following removal of loosened screws in June 2004. The CI’s current level of tolerated activity was described as walking up to 10 minutes, two flights of stairs, bicycle/standing up to 10 minutes, and swimming up to 50 to 75 feet. He was unable to run, jog, or perform other impact activities without significant pain. The examiner diagnosed: multisystem trauma, right knee pain related to healed patellar fracture and popliteus tendonitis, left foot pain secondary to subluxed first MT bone from poorly healed fracture, low back pain, stable right femur fracture (status post ORIF), right hip pain resolved with hardware removal, healing bilateral metatarsal fractures, healed left first rib fracture, and status post left EHL repair. Physical limitations included no shipboard duty or overseas deployment, and physical activity as tolerated with no marching or running. The examiner stated that the CI did not meet the standards of full and unrestricted duties of his rate or rank.

The 11 January 2005 non-medical assessment, 4 months before separation, repeated the commanding officer’s 22 April 2004 recommendation that the CI not be retained because he could not engage in physical activity and was not worldwide assignable.

The 28 January 2005 MEB pain rehabilitation addendum, 3 months prior to separation, noted the CI had “developed chronic right knee and left foot pain,” and that the hardware removal surgery resulted “in a small decrease in his pain afterwards.” The examiner referenced a January 2005 pain clinic visit at which the CI reported low back pain for 6 months that he had not previously mentioned. At the time, physical findings were negative for tenderness, facet/sacroiliac joint pain, or radiculopathy. Myofascial back pain was diagnosed and stretching exercises were recommended. An STR entry noted the CI first reported back pain in the fall of 2004, but there was no record of a diagnosis or treatment.

The 7 February 2005 MEB orthopedic addendum documented the CI’s chief complaints as: right hip, right knee and left foot pain that were progressive since the MVA. Walking less than a quarter mile and prolonged standing exacerbated his pain, and he was unable to do squats or stairs. The orthopedist noted that PT and other conservative interventions, to include pain medications, did not provide relief, and recommended continued non-surgical management. Documented diagnoses were: status post multi-trauma with right femur fracture, left EHL tendon repair, multiple fractures of right foot and left great toe, and rib fractures, with chronic pain status post trauma. The examiner noted CI failed retention standards and recommended a MEB.

Based on the STR evidence, the panel noted that the right hip, right knee, and left foot conditions were the only residuals of the MVA-related multisystem trauma that resulted in persistent duty restrictions for the CI after 23 months of LIMDU and medical treatment. As noted above, there were numerous diagnoses listed by the LIMDU extension board and MEB NARSUM and orthopedic addendum. However, all three assessments documented continued right hip and/or right knee, and left foot pain after the CI had recovered from his other injuries. The orthopedic addendum most clearly related the CI’s physical limitations and mobility restrictions.

Panel members thus concluded that the preponderance of evidence demonstrates the right hip, right knee and left foot conditions individually rendered the CI unable to perform his full duties at the time of separation and are thereby unfitting and eligible for disability rating. The panel noted the MEB referred the bilateral metatarsal fractures and agreed that when unbundling the left and right foot conditions, there was no evidence of unfitting residuals of the right foot. Moreover, the left foot pain was a residual of the metatarsal, and only one rating may be assigned for a single impairment IAW the VASRD. So, panel members considered the left foot pain and unbundled left metatarsal fracture as a single condition. Similarly, the persistent right hip pain was a residual of the femur fracture, so panel members considered both as a single condition. “Multisystem trauma” was a description of the acute result of the MVA, and because the CI recovered from all injuries sustained in the MVA except the right hip, right knee, and left foot pain, the panel did not consider multisystem trauma to be an unfitting condition at separation. Additionally, the panel majority concluded that there was not a preponderance of evidence to show the back condition was unfitting at separation. The condition had not been recommended for a period of limited duty and there is no evidence that it continued despite an appropriate course of treatment. The evidence for each unfitting condition is presented below with attendant recommendations.

Right Knee Pain. At an orthopedic visit on 26 July 2004, 9 months prior to separation, the CI reported right lateral knee pain, and the examiner documented a stable knee with full range of motion (ROM) but lateral tenderness. On 20 September 2004, a primary care provider noted complaints of right knee pain and recorded an antalgic gait as well as tenderness with valgus stress. In October 2004, an MRI revealed a normal right knee without internal derangement. At

a follow-up orthopedic examination on 1 November 2004, the CI reported continued right lateral knee pain, and the provider noted tenderness posterior to the lateral collateral ligament. The CI received an injection for possible popliteus tendonitis but without noted benefit.

At the MEB NARSUM examination, the CI reported right knee pain thought to be due to possible popliteus tendonitis, and continued PT was planned. The examiner documented a normal gait but did not record specific physical findings for the right knee. The 10 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), noted right knee pain rated at 5-6/10 and aggravated by driving. No physical findings were documented for the knee.

The MEB pain rehabilitation and orthopedic addendums noted treatment for chronic right knee that had worsened since the MVA. The CI reported pain, tightness and limited ROM, pain with walking, and swelling and pain with prolonged standing. He had undergone steroid injections for tendonitis without relief. Physical examination showed a large, well-healed scar over the right knee, and lateral (but no medial) joint line tenderness. There was patellar crepitus, but the knee was stable with no signs of meniscal damage. Measured right knee ROM revealed flexion from - 5-135 degrees (normal 0-140).

Although the 9 May 2006 VA Compensation and Pension (C&P) examination, 12 months after separation, was not in evidence, the 27 November 2006 VA Rating Decision (VARD) cited the examination findings, which noted full right knee ROM and X-rays showing degenerative changes. No other medical evidence was cited.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the knee as part of overall effect totaling 0%, using no VASRD code. The VA rated the right knee 0%, coded 5003 (degenerative arthritis), based on the C&P examination, citing full ROM and no evidence of painful motion. Panel members noted the MEB orthopedic addendum was the most proximate to separation and recorded limited right knee flexion with patellar crepitus. The panel majority agreed this warranted a 10% rating for limited motion, coded 5099- 5024, while the minority found no evidence for rating higher than 0%. While there was a history of right femur fracture (5255), X-rays showed adequate alignment after healing, and there was no concern from providers that the right knee pain was due to the fracture or related hardware. The panel considered other VASRD knee and analogous codes, but all were not applicable nor advantageous for rating. After due deliberation, considering all the evidence, the panel majority recommends a disability rating of 10% for the right knee condition, coded 5099-5024.

Right Hip Pain/Femur Fracture. Right femur X-rays on 14 August 2003 following the ORIF surgery showed good position without any hardware problems, but in June 2004, the CI underwent removal of the two proximal screws due to loosening and associated right hip pain. Follow-up X- rays showed no evidence of acute fracture or dislocation, and no complication with the remaining hardware. An STR note on 6 July 2004 indicated the CI was treated after developing an infection related to the screw removal while on convalescent leave; an orthopedic visit on 26 July 2004 noted decreased symptoms.

According to the MEB NARSUM, the CI’s hip pain resolved after the hardware removal. The examiner recorded a normal gait but did not document any other findings for the right hip or femur. At the MEB examination, the CI reported no complaints related to the right hip/femur.

The MEB pain rehabilitation addendum noted that the June 2004 hardware removal procedure only provided a small amount of pain relief. The MEB orthopedic addendum recorded complaints of constant right hip pain and popping with walking, but no swelling. Measured ROM showed right hip flexion to 120 degrees (normal 125), abduction to 60 degrees (normal 45), external rotation to “about” 45 degrees (normal 60), and internal rotation also to about 45 degrees

(normal 40). Painful motion was noted at flexion and internal rotation endpoints. Quadricep strength was 4/5 and limited by pain.

The November 2006 VARD cited right hip flexion to 110 degrees, extension to 20 degrees. abduction to 35 degrees, and external/internal rotation to 35 degrees; painful motion was noted in all planes of motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right hip and right femur as part of overall effect totaling 0%. The VA rated the right hip and femur 10%, coded 5253 (impairment of the thigh), based on the 2006 C&P examination, citing limited adduction with inability to cross the legs, and limited rotation with inability to toe-out more than 15 degrees. While there was no evidence to support a compensable rating for limitation of thigh flexion, extension, or thigh impairment (5252, 5251, 5253), there was evidence of painful motion with functional loss at both the MEB orthopedic addendum and VA examinations to support a 10% rating (based on §4.59, §4.40 and §4.45), coded 5299-5252. As noted above, the panel determined that alternative rating for femur impairment was not supported. There was also no hip ankyloses or flail hip joint for a rating under those respective codes (5250, 5254). After due deliberation, considering all the evidence, the panel recommends a disability rating of 10% for the right hip pain/femur fracture, coded 5299-5252.

Left Foot Pain/Metatarsal Fracture. At the time of the June 2003 MVA, X-rays revealed fracture of the left first metatarsal, and examination showed a laceration of the left foot EHL tendon. The CI underwent surgical repair and closed reduction with casting. At an orthopedic appointment on 19 March 2004, the CI reported mild left foot pain, and X-rays showed healing of the fracture, but with a persistent subluxation of the tarsometatarsal joint; the assessment included follow- up for possible foot fusion if symptoms continued. Physical findings for LIMDU extension board noted a normal gait. Weight bearing foot X-rays on 30 April 2004 showed healing of the fracture and an orthopedic follow-up on 26 July 2004 noted occasional foot pain. There was no further indication in the record that surgery for fusion of the left foot occurred or was planned.

The MEB NARSUM documented continued/stable left foot pain, normal gait, and medial left foot hypersensitivity. Left foot X-rays on 19 November 2004 showed post traumatic deformity of the first metatarsal medial cuneiform articulation. The MEB examination revealed decreased left foot sensation.

The MEB pain rehabilitation addendum noted treatment for chronic left foot pain and the orthopedic addendum recorded complaints of ongoing left foot pain and swelling caused by walking less than a quarter mile. The CI denied motor loss following the EHL repair. Physical examination of the left foot showed residual swelling, diffuse mid-foot tenderness, and decreased sensation in the deep peroneal distribution between the first and second toe. Strength was 5/5 for the lower leg and 4/5 for the great toe; pulses were normal.

The November 2005 VARD noted foot tenderness, but no limitation with standing or walking, and no required shoe support. Gross examination of the foot muscles and joints was normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated both feet as part of overall effect totaling 0%. The VA rated the left foot 0%, coded 5284 (foot injuries, other), based on the 2006 C&P examination, citing an absence of moderate symptoms associated with foot injury. Panel members considered rating the left foot condition as malunion of a metatarsal bone under code 5283; the ratings under this code are subjective, with a threshold rating of 10% for moderate malunion. While one primary care examination noted an antalgic gait (September 2004) during a visit for knee pain, the remainder of the STR entries in the 12 months prior to separation showed a normal gait. Thus, the panel agreed no

higher than a 0% rating was supported for the left foot for mild malunion. Panel members also agreed no higher than a 0% rating was supported under code 5284 (other foot injuries), which is rated subjectively with a threshold rating of 10% for moderate injury. The panel considered other VASRD foot and analogous codes, but all were not applicable nor advantageous for rating. After due deliberation, considering all the evidence, the panel recommends a disability rating of 0% for the left foot pain/metatarsal fracture, coded 5283.

BOARD FINDINGS: In the matter of the overall effect of the right knee pain, right femur fracture/hip pain, left foot pain, bilateral metatarsal fractures, multisystem trauma, and low back pain, the panel recommends: an unfitting right knee condition with a disability rating of 10% (by majority vote), coded 5099-5024 (the single voter for dissent recommends a 0% rating and did not elect to submit a minority opinion); an unfitting right hip/femur condition with a disability rating of 10%, coded 5299-5252; and an unfitting left foot/metatarsal fracture condition with a disability rating of 0%, coded 5283, all IAW VASRD §4.71a. In the matters of the right metatarsal fractures, multisystem trauma and low back pain, the panel agrees that it cannot recommend a finding of unfit for any of these conditions for additional disability ratings. 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	
Right Knee Pain	5099-5024	10%	
Right Hip Pain/Femur Fracture	5299-5252	10%	
Left Foot Pain/Metatarsal Fracture	5283	0%	
	COMBINED	20%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20210430, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Record

10/14/2022

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THE ASSISTANT SECRETARY OF THE NAVY
(MANPOWER AND RESERVE AFFAIRS) I 000 NAVY PENTAGON
WASHINGTON, D. C. 20350-1000

6040
Memo 00/01 26 Oct 22

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
Subj:	 PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS Ref:	(a) DODI 6040.44
(b) PDBR ltr dtd 14 Oct 22 ICO

1.	Pursuant to reference (b), the recommendation of the Physical Disability Board of Review set forth in reference (b) is approved. The official record of the following individual is to be corrected as follows:

XXXXXXXX former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from O percent), effective date of discharge.

2.	Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.