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AF | PDBR | CY2013 | PD-2013-01387
Original file (PD-2013-01387.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-01387
BRANCH OF SERVICE: Army  BOARD DATE: 20141025
SEPARATION DATE: 20050222


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army SPC/E-4 (19D10/Cavalry Scout) medically separated for post-traumatic arthritis left knee condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The left knee condition, characterized as “left knee post traumatic arthritis”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was identified and forwarded by the MEB for PEB adjudication. The Informal PEB adjudicated “posttraumatic arthritis, left knee, secondary to gunshot wound” as unfitting, rated at 10%. The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in his application.


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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting left knee condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Corrections of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20041202 VA –(Exam ~ 4 Mos. Post-Separation)
Condition Code Rating Condition Code Rating Exam
Posttraumatic Arthritis, Left Knee, Secondary to Gunshot Wound (GSW) 5010 10% Residual of GSW to the Left Knee with Traumatic Arthritis and Partial Left Saphenous and Sural Nerve Injuries 5311 30% 20050627
Scars, Residual GSW to Left Knee 7801 20% 20050627
Scars, Donor Site, Left Thigh and Pin Hole Scars, Residual, Fixation Device 7805 0% 20050627
Other x 4 (Not in Scope) Other x 5 (Not in Scope)
Combined: 10% Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 51017 (closest available in evid ence to date of separation )
Note: The original VARD dated 20050223 is not available for review. The VARD dated 20051017 details an increase of 10% an added condition of bilateral shoulder arthritis from the original rating, effective 20050627. Combined original rating was 40%.


ANALYSIS SUMMARY: The PEB combined aspects of the CI’s left leg gunshot wound (GSW) including nerve and scar sequlae as a single unfitting and solely rated condition, coded as 5010, using VASRD criteria. The Board may apply separate codes and ratings in its recommendations, if compensable ratings for each component of the single traumatic injury are achieved IAW application of the VASRD considering the total disability picture from the single GSW. If the Board judges that two or more separate ratings are warranted, however, it must satisfy the requirement that each “unbundled” condition were unfitting in and of itself. The multiple ratings from the Department of Veterans Affairs (DVA) reflected that in the chart above, for diagnoses of saphenous and sural nerve injuries and multiple scars of the left knee were all considered sequelae of the GSW and are addressed below. The issues for adjudication are the various components of the CI’s GSW injury and which portions were unfitting and ratable at the time of separation.

Post-traumatic Arthritis, Left Knee, Secondary to GSW. While deployed on 18 August 2003, the CI received a high velocity GSW in the left leg (across the knee) that resulted in a multiple fragmented fracture of the tibial plateau, fractured kneecap and a large soft tissue defect. The case file did not comment on the presence of any exit wound. He was evacuated from theater and underwent several surgeries for wound debridement, wound grafting (rotation flap from calf muscle) and external boney fixation. Post-operatively, he did well whereby repeat X-rays images obtained (5 and 8 months) after the incident revealed “some” separation of bone fragments with progressive healing, a stable fracture line and intact boney articular surfaces. He underwent extensive physical therapy (PT) for muscle strengthening and range-of-motion (ROM) control.

The MEB physical examination, conducted on 30 July 2004 (7 months prior to separation), revealed a 5 x 12 centimeter skin graft over the left medial knee and over the upper tibial bone. There was tenderness and decreased ROM of the left knee as well as diminished sensation along the medial shin and outer left foot. The left quadriceps muscle revealed significant atrophy. There was no ligamentous laxity, warmth, or effusion noted. There was no comment about painful motion, guarding, crepitus, motor loss, or abnormal vascular findings. The diagnosis was post-traumatic arthritis and his prognosis was described as “stable”.

The commander’s statement dated 26 July 2004, included the CI’s duty limitations and noted the inability to perform his required MOS duties.

The MEB narrative summary (NARSUM) dated 12 November 2004 (3 months prior to separation), documented that the CI had continued intermittent left knee pain with prolonged weight-bearing or flexing of the knee. It was noted “he is able to ride a bicycle without difficulty but notes pain after resting for a few minutes”. His permanent profile dated 2 December 2004 singularly implicated the left knee arthritis condition.

At the VA Compensation and Pension (C&P) examination on 27 June 2005 (4 month post separation), the CI reported near constant left knee pain ranging from 3-6/10 pain scale, worsened with extreme bending of the knee; otherwise, he denied “flare-ups”. Additionally, he endorsed weakness, stiffness, swelling, fatigability and numbness of his calf below his surgery site. The physical examination revealed an antalgic gait, decreased, painful motion and measured atrophy to the left thigh and calf. It also noted “he has numbness distal to the skin graft as far as the ankle as well as to the lateral heel that’s associated with tingling in the left 4th and 5th toes.” Also the CI noted, “has lost sensation” corresponding to the saphenous and sural nerves. There was “some” laxity on the medial side of the knee. All other directional stability tests were normal. There was no comment regarding crepitus, guarding, or abnormal neurovascular findings. The diagnosis was the same as described above. It was noted “he currently works for Brinks”. The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.



Left Knee ROM
(Degrees)		 MEB ~3 Mo. Pre-Sep
(20041112)
VA C&P ~4 Mo. Post-Sep
(20050627)
Flexion (140 Normal) 103 105
Extension (0 Normal) 0 0
Comment decrease sensation; tenderness antalgic gait; painful motion; (+) atrophy
§4.71a Rating 0-10% 10%

The Board directs attention to its rating recommendation based on the above evidence. Board members first reviewed the PEB’s coding/rating determination in this case. While the diagnosis of traumatic arthritis is undisputed and the CI may have experienced some variable residual symptoms, the PEB’s ultimate determination left room for further elucidation of the unfitting condition. It appeared that pain and loss of motion were the principle components to the PEB’s unfit determination. All exams demonstrated either tenderness or painful motion without reaching the flexion or extension limits for rating under the specific codes for the knee. Instability was not a significant factor in this case.

Board members agreed that application of either VASRD 4.59 (painful motion) or 4.40 (functional loss) as evidenced secondary to measured atrophy is supported at the current PEB rating of 10%. 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 left knee condition, noted as traumatic arthritis secondary to the GSW.

Partial Left Saphenous and Sural Nerve Injuries; GSW Residuals. Board members acknowledged that although radiologic evidence was present near the time of the PEB’s rating, additional evidence more proximal to separation revealed loss of sensation into the left lower leg, foot, and toes. Members considered that the service treatment record (STR) substantially reflected pain and limitation of motion as major contributors in determining fitness in this case. However, the loss of sensation as revealed at the VA examination was cause for functional limitations in evidence to justify a conclusion that the altered nerve condition was integral to the CI’s inability to perform his worldwide MOS duties and accordingly a separate rating is recommended. Members agreed that code 8527 (saphenous nerve) is anatomically appropriate to the abnormal objective findings and renders a maximum of 10% impairment rating. Board members also considered coding under §4.73 (muscle injuries), due to the need for a muscle flap wound closure, but consensus was that the mere surgical muscular intervention, in and of itself, did not support a separately unfitting condition e.g. functionally, he was riding a bike quite well. Board members extensively deliberated over rating under a specified muscle code and eventually agreed that the injury taken through the knee did not involve a great degree of muscle involvement. Acknowledging the fact of using a small amount of muscle in its surgical repair, the original injury caused more boney involvement and limited muscle damage. The more functionally significant injury was the residual to the local nervous system.

After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the residual nerve injuries favors its recommendation as an additionally unfitting condition for disability rated at 10% under code 8527.

Scars; Left Knee, Donor Site, Left Thigh and Pin Holes Scars; GSW Residuals. Despite minor “pin holes,” the VA exam detailed the presence of three separate large scars; two linear and a donor graft site, measuring 74 square centimeters in total area. All were described as painful and adhering to underlying tissue. The MEB nor the PEB addressed painful scars. By precedent, the Board does not recommend disability rating for scars unless their presence imposes a direct limitation on fitness. In this case the scars imposed an indirect effect of pain and decreased knee ROM which is supported by the VA examiner’s statement of, “there is limitation of motion and function caused by the scars in that [the CI] cannot fully flex left knee, had pain and pulling sensation”. Board members agreed that such scar related symptoms are subsumed under the current arthritic rating utilized by the PEB and therefore concluded that the painful scars condition could not be recommended for a separate disability rating.


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 post-traumatic arthritis, left knee, secondary to GSW condition, the Board unanimously recommends no change in the PEB adjudication. In the matter of the left leg peripheral nerve condition, the Board unanimously agrees that it was separately unfitting and recommends a disability rating of 10% (maximum available per appropriate nerve code). In the matter of the scars condition, the Board unanimously agrees that they were not independently unfitting and therefore not ratable for service disability. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Post-traumatic Arthritis, Left Knee, Secondary to GSW 5010 10%
Left Saphenous and Sural Nerve Injuries 8527 10%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130903, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record







                 
XXXXXXXXXXXXXXXXX
President
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, AR2015002679 (PD201301387)
1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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