RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02131
BRANCH OF SERVICE:  Army	BOARD DATE:  20150326
SEPARATION DATE:  20050327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Legal Specialist) medically separated for right leg pain and right ankle weakness and right knee pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Right tibial plateau fracture,” “right ACL avulsion,” “popliteal artery laceration,” “sciatic nerve injuries,” and “arthrofibrosis” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (contralateral patellar tendonitis) for PEB adjudication.  The Informal PEB adjudicated “right leg pain and right ankle weakness status post tibial plateau fracture with neurovascular compromise” and “right knee pain” as unfitting, rated 10% and 10%, respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition (left knee) was determined to be not unfitting.  The CI made no appeals and was medically separated.  A PEB Administrative Correction was completed to correct the disability descriptions; this correction had no bearing on the rating.

CI CONTENTION:  “I was not given the proper evaluation prior to my discharge.  I also did not receive a mental evaluation prior to my discharge.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited 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 PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Admin PEB – Dated 20041116 | VA* - (~10 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Right Leg Pain and Right Ankle Weakness | 8523 | 10% | S/P Fracture of the Medial Tibial Plateau | 5260 | 10% | 20060116
Right Knee Pain | 5003 | 10% | | | |
Other x 1 (Not In Scope) | Other x 8
COMBINED RATING:  20% | COMBINED RATING:  60%
*Derived from VA Rating Decision (VARD) dated 20060418 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board considered that the traumatic incident resulted in multiple injuries to the right lower extremity (RLE).  Therefore, the history of the injuries and immediate surgeries are presented together in an introduction, followed by separate discussions of the two residual conditions identified by the PEB and adjudicated as unfitting.

The Board also noted that the MEB forwarded five RLE conditions to the PEB and the PEB characterized two unfitting conditions: “right knee pain,” which included the MEB listed conditions of right anterior cruciate ligament (ACL) avulsion, post-operative knee arthrofibrosis, and popliteal artery laceration and “right leg pain and right ankle weakness”, which included the MEB conditions of right tibial plateau fracture and sciatic nerve injury.  If conditions are bundled by the PEB for rating, the Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD rating guidelines.  To that end in the discussion below, Members first deliberated whether the “right leg pain and right ankle weakness” condition or the “right knee pain” were a bundled conditions, and if so, if each “unbundled” condition was unfitting in and of itself, and therefore eligible for individual disability rating, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Introduction Right Lower Extremity Conditions.  The narrative summary (NARSUM) noted the CI sustained a closed right proximal tibial fracture in August 2004.  Notes in the service treatment record indicated the CI’s right leg gave out while she was running during physical training and she fell to the pavement.  Right knee magnetic resonance imaging on 3 August 2004 showed a tibial plateau fracture and an avulsion fracture, with tears of the anterior cruciate and medial collateral ligaments.  The CI was immediately transferred to a civilian facility for evaluation of suspected (RLE) vascular damage.  Angiography showed occlusion of the popliteal artery at the knee joint and the CI had surgery for popliteal revascularization on 5 August 2004 without complications.  On 10 August 2004, the CI had orthopedic surgery for open reduction internal fixation of the tibial fracture and repair of ruptured anterior and posterior cruciate ligaments without complications.  The discharge summary noted that on arrival at the facility the CI had numbness of the sole of the right foot, with weakness of plantar flexion thought to be due to a posterior tibial nerve stretch injury at the time of the initial hyperextension injury and not due to the development of a compartment syndrome.  Two weeks later the CI had improved sensation in the sole of the foot and was able to weakly plantar fascitis the foot.  She was considered stable and was discharged back to the Military Treatment Facility (MTF) on 14 August 2004 for continued inpatient care.

Right Leg Pain and Ankle Weakness Condition (Right Leg Condition).  According to the NARSUM after transfer back to the MTF, the CI participated in physical therapy (PT) and although the RLE neurological injury improved, the CI continued with right foot weakness.  At the MEB examination on 30 0ctober 2004, 5 months prior to separation, the CI was partial weight bearing on the RLE with crutches and using a range-of-motion brace.  The CI was less than 3 months from her initial injuries and a few weeks after an arthroscopic surgery for knee adhesions.  The MEB physical exam noted right foot weakness graded 4/5 (can move against some resistance) of great toe extension and graded 3/5 (can move against gravity) for flexion of all toes.

At the VA Compensation and Pension (C&P) examination 16 January 2006, 10 months after separation, the CI reported pain from the right knee to the foot, with at times numbness of the right foot.  She reported difficulty with walking and current treatment of blood thinners and medication for nerve related pain (Neurontin).  The exam noted normal posture and gait without use of a cane or crutch.  There was tenderness to palpation (TTP) of the front and outer aspect of the lower leg.  There was normal LE strength noted with decreased sensation of the top of the foot and the inside of the lower leg.  Reflexes of the RLE were present, but decreased compared with the left.  The ankle exam was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB characterized the right leg condition as “right leg pain and ankle weakness” and rated 10%, coded 8523 (incomplete paralysis of the anterior tibial nerve).  The only rating the VA provided for the RLE was for the knee condition discussed below.  As outlined in the analysis summary above, the Board first deliberated whether conditions of “right tibial plateau fracture” and “sciatic nerve injury” were separately unfitting conditions when separated from the PEB’s combined adjudication.  The Board noted that the PEB adjudicated two unfitting conditions, the other condition being “right knee pain” and members readily agreed that although the tibial fracture was eligible for disability rating apart from the residuals of sensory and motor deficit related to the nerve injury, it would need to be considered again below with the right knee pain condition to see if it was truly a third, separately unfitting condition, and eligible for additional disability rating.  The Board next considered if the “ankle weakness” was a separate condition from the residual nerve impairment.  There was no injury of the ankle joint diagnosed in the service treatment record and based on the evidence in record, the “ankle weakness” referred to weakness related to nerve injury and at the post-separation C&P exam, the ankle exam was normal.  Member consensus was that there was no evidence of an ankle condition that could be recommended as separately unfitting.  Although other factors may have contributed to pain of the lower leg, they cannot be separately rated for the symptom of pain IAW VASRD §4.14 (Avoidance of pyramiding).

At this juncture the Board agreed that the right leg condition was a single unfitting condition and considered its rating.  The evidence in record supports that the CI had residual pain with TTP of front and outer aspect of the lower leg and decreased sensation of the inner aspect of the lower leg and top of the foot.  There was mild to moderate weakness of the toes noted at the MEB exam, but at the C&P exam motor function of all extremities was reported as normal.  The sciatic nerve courses down the posterior LE and branches into the common peroneal and tibial nerves behind the knee and both nerves were implicated in the record.  Therefore, the Board concluded that coding as incomplete paralysis of the sciatic nerve captured any contribution to disability related to both nerves.  The rating criteria of 8520 (incomplete paralysis of the sciatic nerve) are subjective and provide 10% rating for “mild” and 20% for “moderate” incomplete paralysis.  The Board agreed that the disability due to the right leg condition due to residual pain and sensory deficits, with normal motor function and gait, was best described as mild and rated 10%.  The Board noted that the PEB coded the neuropathy using a more distal nerve (anterior tibial nerve) and provided a 10% rating also.  The Board found that its deliberations resulted in no ratings benefit to the CI, and therefore, no change to the PEB’s coding choice is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the “right leg pain and right ankle weakness” condition.

Right Knee Condition.  According to the NARSUM after transfer back to the MTF the CI was in PT, but plateaued at knee ROM of 0-85 degrees (normal (0-140).  Arthroscopy was performed in October 2004 for lysis of adhesions (arthrofibrosis) to improve ROM.  At the MEB examination on 30 0ctober 2004, 5 months prior to separation, the CI was still in the early convalescent period of her injuries and was partial weight bearing on the RLE as noted above.  The MEB physical exam noted ROM of 0-130 degrees, with painful motion.  There was no anterior instability, but mild lateral laxity was noted.  The examiner commented that it was difficult to define the CI’s final functional status at the time and it would take 8 to 12 months for full recovery.

At the VA C&P examination 16 January 2006, 10 months after separation, the CI reported constant right knee pain and stiffness aggravated by weight bearing activities and a limp.  She reported she was in PT and took pain medication regularly.  The exam noted normal posture and gait, without use of a cane or crutch.  There was no swelling, tenderness or abnormal movement of the knee noted.  Right knee ROM was 0-105 degrees, with pain starting at 90 degrees.  The C&P examiner indicated he was unable to accurately evaluate for stability or cartilage damage due to decreased ROM and pain.  Right knee X-rays noted degenerative arthritis.  A VA orthopedic outpatient treatment note on 14 June 2007, 27 months after separation, indicated the CI was seen for her right knee and had traumatic arthritis without X-ray changes, with some swelling of the RLE, but without instability.  The VA examiner indicated the CI was not a candidate for any type of surgery and prescribed anti-inflammatory medication.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5003 and cited degenerative joint disease with loss of motion.  The VA rated the knee condition 10%, coded 5260 (limited knee flexion).  As outlined in the analysis summary above, the Board first considered whether the conditions of right ACL avulsion, post-operative knee arthrofibrosis, and popliteal artery laceration were separately unfitting conditions when separated from the PEB’s combined adjudication.  Members considered that the vascular injury was a discrete injury from the musculoskeletal knee injuries and would potentially be eligible for separate disability rating.  However, there was no evidence in record of residual vascular impairment following the revascularization procedure.  Therefore, the Board consensus was that there was no unfitting vascular condition that could be recommended as unfitting.  

The Board next reviewed the MEB forwarded conditions of ACL avulsion and knee arthrofibrosis, along with the tibial fracture as noted above.  Members noted that rating any of these conditions with knee codes IAW 4.71a would include consideration of impairment due to knee pain, limited ROM, and instability.  Therefore, the Board concluded that although the knee condition can be considered for multiple ratings for limited flexion, extension, and instability according to VA guidance in effect at the time of separation, the individual symptoms cannot be rated multiple times under different diagnoses IAW VASRD §4.14 (Avoidance of pyramiding).  

The Board next considered the rating of the knee condition and agreed that the evidence in record supports a 10% rating coded as either 5003 for painful limited ROM of one joint with X-ray evidence of degenerative arthritis or with a ROM code IAW VASRD §4.59 (Painful motion).  There was no evidence to support a higher rating based on limited ROM alone and there was no evidence of symptoms due to cartilage injury, ankylosis, or impairment of the fibula or femur.  Members considered if a higher rating was supported coded analogously to 5262 (impairment of the tibia), which has subjective rating criteria of 10% for slight, 20% for moderate, or 30% for marked knee disability.  The Board opined that in this case the initial VA C&P examination was the better examination for the purposes of assessing the CI’s permanent impairment due to her RLE injuries than the MEB examination, which occurred in close proximity to the CI’s injury and related surgeries, while she was still in the post-operative convalescence period.  At the C&P examination the CI reported pain and stiffness of the knee limited her activities.  The exam noted a normal gait and no abnormalities were noted except for pain and limited ROM.  Member consensus was that based upon the C&P evidence the permanent disability due to the knee condition was best rated 10% whether coded as 5262 or 5003.  

The Board also considered if the evidence supports rating the knee for both instability and limited ROM.  There was no evidence in record of anterior/posterior instability after the surgical repair of the ACL and posterior cruciate ligament ligaments.  The C&P examiner reported that he was not able to obtain accurate clinical assessment of stability or cartilage injury.  However, the CI did not report any symptoms of instability and the remote VA orthopedic treatment note in 2007 noted no instability.  The diagnosis remained traumatic arthritis, consistent with the MEB and C&P exams.  Members concluded there was insufficient evidence of residual instability after the CI’s convalescence to recommend additional rating of the knee for instability.  

The Board found that its deliberations resulted in no ratings benefit to the CI, and therefore, no change to the PEB’s coding choice is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right leg condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131030, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150011172 (PD201302131)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl			     XXXXXXXXXXXXXXX
				     Deputy Assistant Secretary of the Army
				          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02131