RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300225
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140107
DATE OF PLACEMENT ON TDRL:  20010104
Date of Permanent SEPARATION:  20060310

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SA/E-2 (Seaman Apprentice) medically separated for right greater trochanteric stress fracture.  Onset of pain was at boot camp in 2000 where she complained of bilateral knee and right hip pain.  Neither condition could be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on light duty and referred for a Medical Evaluation Board (MEB).  The hip and knee conditions, characterized as “bilateral medical tibial plateau stress fracture” and “right greater trochanteric stress fracture,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated the right hip and bilateral knee conditions as unfitting, rated 20% and 10%, respectively, and the CI was placed on the Temporary Disability Retired List (TDRL) with a combined disability rating of 30%.  At the TDRL re-evaluation 5 years later, the IPEB adjudicated the right hip condition as unfitting, rated 20%.  The bilateral knee condition was changed to a Category III: conditions that are not separately unfitting and do not contribute to the unfitting condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “skeletal issues still remain however seizure condition rendered me unfit and I have been 100% P nT” [sic] 

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 ratings for the unfitting right hip and bilateral knee conditions are addressed below.  The contended seizure condition was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board; 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 Correction of Naval Records.

RATING COMPARISON:

Final Service PEB - 20060106	VA - Effective 20001107	
On TDRL - 20001114	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
R … Trochanteric Stress Fx	5003 -5255	20%	20%	Stress Change, R Hip 	5299-5255	10%	20001107	
Bilateral Medial Tibial Plateau Stress Fx’s	5022-5003	10%	Cat III	R … Stress Change	5299-5262	10%	20001107	
	5022-5003	0%	Cat III	L … Stress Change	5299-5262	10%	20001107	
No Additional MEB/PEB Entries.	Other x 4	20001107	
Combined: 30% → 20%	Combined: 30%	
*Reflects VA rating exam proximate to TDRL placement; no VA rating evidence proximate to permanent separation.  The seizure disorder was determined to be service connected as it began within one year of separation (TDRL entry.)
ANALYSIS SUMMARY:

Right Hip. The CI developed atraumatic right hip and bilateral knee pain during the first several weeks of basic training.  The pain continued despite conservative management.  A bone scan performed on 12 October 2000, a month after enlistment, was significant for healing stress fractures of the bilateral medial tibial condyles and suggestive of a stress fracture of the right greater trochanter (hip.)  She was unable to complete basic training and thought that it could take up to a year for complete healing.  She was then entered into the Disability Evaluation System process.  The CI reported bilateral knee pain and pain with ambulation.  The examiner noted tenderness over both tibiae and a positive right hip fulcrum test (consistent with a stress fracture.)  She was diagnosed with stress fractures of the medial tibial plateaus bilaterally and the right greater trochanter.  At the VA Compensation and Pension (C&P) examination on 7 November 2000, the CI reported that she was non-weight bearing on her right leg and using crutches.  She had developed both back and ankle pain from the use of the crutches.  Straight leg raise was painful at 75 degrees on the right lateral hip, but painless to 90 degrees on the left.  External rotation and abduction were both to 60 degrees bilaterally, but painful on the right.  Motor function was normal and no instability detected.  The PEB and VA both used VASRD code 5255 (impairment of the femur), but the PEB used it in combination with 5003, degenerative arthritis, and the VA used it as an analogous code, rating the hip at 20% and 10%, respectively.  The Board observed that there is no specific code for a stress fracture and then considered the different coding options available for the hip condition.  It found no route to a rating higher than 10%, but noted that the Board does not recommend a combined rating lower than that assigned by the PEB.

The Board then considered the permanent disability rating for the right hip condition.  The CI was seen in physical therapy (PT) on numerous occasions for back, right shoulder, right hip, and bilateral knee pain the first 6 months after TDRL entry.  A 21 August 2001 note in the rehabilitation clinic noted that she had numerous no-shows and cancellations in pain management and PT.  Her examination showed poor effort and was noted as inconsistent in the assessment.  X-rays performed on 2 November 2005, were normal.  An examination that same day noted that she was non-tender over the proximal tibiae and right proximal femur, but that she continued to complain of pain.  The hip motion was symmetric with 30 degrees of internal rotation and 6 degrees of external rotation (it is thought that this is a typo as it was 60 degrees bilaterally at TDRL entry and the finding was symmetric.)  She had a 10 degree flexion contracture of the right hip which was not further addressed including a statement of limitation in range-of-motion (ROM) or function.  She was able to voluntarily and painlessly subluxate her right hip.  Her gait was mildly antalgic without crutches.  The stress fractures were thought to be resolved.  There were no clinical records or VA C&P examinations proximate to TDRL exit in evidence.  However, a 28 January 2008 C&P examination performed for an evaluation of epilepsy, was documented on the 9 May 2008 VA rating decision as showing normal bilateral upper and lower extremity motor and sensory functions.  A 22 September 2010 neurology note documented a normal posture and gait as well as a normal lower extremity neurological examination.  While these examinations are outside the normal 12-month period assigned for higher probative value, they serve to indicate that the flexion contracture observed at the TDRL exit examination was not a permanent finding.

The Board directs attention to its rating recommendation based on the above evidence.  While the external rotation was documented as 6 degrees, this is thought to be an error as discussed above.  The CI was not tender on examination and subsequent neurological examinations were normal and also documented normal gait and posture.  Again, the Board found no route to a rating higher than 10%, but noted that it does not recommend a combined rating lower than that assigned by the PEB.

Bilateral Knees. The CI also developed bilateral knee pain within the first few weeks of basic training.  Again, conservative management failed and a bone scan showed the presence of bilateral stress fractures.  At the MEB NARSUM, she reported bilateral knee pain after physical fitness training.  On examination, she was tender over both proximal tibiae without edema.  The VA C&P examination noted pain with flexion at 110 degrees on the left and 125 degrees on the right.  The knee examination was otherwise unremarkable and without instability.  The commander noted that the CI was duty limited from both knees and the right hip.

The Board directs attention to its rating recommendation based on the above evidence for TDRL entry.  The PEB rated the two knees coded 5022-5003, periostitis and degenerative arthritis, and rated them at 10% and 0%.  It is not clear from the record which knee was rated at 10% and which at 0%, although the left knee appeared to be the clinically more significant joint.  The VA used the 5262 coding option, impairment of the tibia and fibula, analogously and rated each at 10%.  The Board determined that the PEB coding option was the better fit clinically, but that each knee warranted a separate 10% rating at TDRL entry.  Each was cited by the commander and the CI reported that both were painful.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board observed that a disability rating of 10% each for the left and right knee conditions at TDRL entry would have been appropriate.

Then Board then considered the permanent rating at TDRL exit.  A 25 July 2001 orthopedic note documented that the bilateral stress fractures were healing.  Weight-bearing X-rays performed on 2 November 2005 documented normal knees other than minimal decrease in the articular cartilage.  The TDRL exit examination noted that she was non-tender over the proximal tibiae and that her ROM was 0-120 degrees bilaterally, but with a mildly antalgic gait.  Again, there was no proximate C&P examination to TDRL exit, but the gait and posture were noted as normal on a 2010 neurology examination.  The PEB determined that the bilateral knee condition was Category III, not separately unfitting nor contributing to the unfitting condition.  The Board considered the findings.  The knees were no longer tender to palpation.  Flexion was reduced bilaterally, but symmetrically, and close to the VA normal value of 140 degrees.  Her gait was antalgic, but subsequently normal.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral knee condition at separation.

The Board then turned its attention to the combined rating for both TDRL entry and exit.  As noted, the Board members determined that the rating for the hip merited a 10% disability rating at TDRL entry and exit.  The knees merited 10% each at TDRL entry and were not unfitting or ratable at TDRL exit.  This would provide a combined rating of 30% at TDRL entry.  It also would warrant a 10% rating at TDRL exit which would lower the PEB adjudication and is not permissible.  The 20% combined PEB rating at TDRL exit must be retained, but would then imply that the hip condition had worsened while on TDRL if the 10% rating at TDRL entry were utilized.  It did not.  The Board determined that, as a higher combined rating at TDRL entry or exit is not supported, it is administratively cleaner to recommend no change in the PEB adjudication.  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 hip or knee conditions at TDRL entry or exit.

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 greater trochanter and bilateral knee conditions 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Stress Change, Right Hip 	5299-5255	20%	20%	
Right Tibial Plateau Stress Change	5299-5262	10%	Cat III	
Left Tibial Plateau Stress Change	5299-5262	0%	Cat III	
COMBINED	30%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130501, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 9 Apr 14

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their respective forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXX, former USN, XXX XX XXXX