RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01511
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20141214
SEPARATION DATE:  20050131

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Seaman Recruit) medically separated for right femoral shaft stress fracture (fx) and medial tibial plateau stress reaction, left.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The stress fracture/reaction conditions, characterized as “right femoral shaft stress fracture” and “medial tibial plateau stress reaction, left” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded four other conditions.  The Informal PEB (IPEB) adjudicated “right femoral shaft stress fracture” and “medial tibial plateau stress reaction, left” as unfitting, rated 10% each, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category II (conditions which contribute to the unfitting condition but are not separately unfitting).  The Category II conditions related to the unfitting right femoral shaft stress fracture were right second metatarsal stress reaction; tibial periostitis, right; and medial tibial plateau stress reaction, right.  Related to the medial tibial plateau stress reaction, left, condition was tibial periostitis, left.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her 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 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 Veterans Affairs Schedule for Rating Disabilities (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:

Service IPEB – Dated 20041202	VA - (6 Mo. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
R Femoral Shaft Stress Fx	5022-5003	10%	Residuals, Stress Fx, Right Lower Extremity, Right, Femur, Tibia, Medial Tibial Plateau, and Right Second Metatarsal Stress Fx	5262	0%	20050719	
L Medial Tibial Plateau Stress Reaction	5022-5003	10%	Residuals, Stress Fracture, Left Lower Extremity, Left Femur and Tibia, Medial Tibial Plateau	5262	0%	20050719	
Combined:  20%	Combined:  0%	
Derived from VA Rating Decision (VARD) dated 20051122 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Femoral Shaft Stress Fracture Condition.  The service treatment record documents that the CI sustained bilateral lower extremity stress fractures (fatigue-induced fractures caused by repetitive stress and overuse) during boot camp less than 2 weeks after accession.  No history of trauma was reported and she was treated with duty limitations and medications.  Her pain persisted and on 24 August 2004 the CI was evaluated by the Sports Medicine and Rehabilitative Therapy Team for lower extremity (LE) pain.  X-rays of both lower leg bones and the right thigh bone were negative.  A 31 August 2004 bone scan showed diffuse stress fractures to include the bilateral mid femurs (thigh bone), mid tibias (shin bone), and medial tibial plateaus (base of the knee).  Treatment included pain medications, cryotherapy, and activity modification.  Most stress fractures resolve with this type of conservative management.  On 20 October 2004, a bone scan showed diminution of the previously described diffuse stress reactions in response to therapy and reduced activity.  In the 8 November 2004 MEB narrative summary, the CI denied a previous history of LE pain or trauma. She complained of bilateral knee and right hip pain which was exacerbated by running, prolonged walking, and prolonged standing.  The CI reported slight relief with medications, light duty, and physical therapy.  Physical exam showed a normal gait.  Musculoskeletal provocative diagnostic tests of the hips, knees, and ankles were negative.  The hips were normal to examination including the range-of-motion (ROM).  The right anterior superior pelvis was tender to palpation.  The knees were also normal.  The tibias were tender at the medial tibial plateaus and shafts.  The ankles and feet showed no tenderness.  Muscle strength (5/5), light touch sensation, deep tendon reflexes, and pulses were normal.  The knee ROMs are summarized in the chart below.  The diagnoses were listed as right femoral shaft stress fracture; bilateral medial tibial plateau stress reactions; right second metatarsal stress reaction; and bilateral tibial periostitis (inflammation of the dense vascular connective tissue enveloping the bones).  At the VA Compensation and Pension exam, 6 months after separation, the CI complained of intermittent lower extremity pain exacerbations (lasting up to 2 days).  Pain involved both thighs and legs and was exacerbated by running, prolonged walking, prolonged standing, prolonged driving, and climbing and descending stairs, but did not result in any time lost from work.  It was relieved with Tylenol.  Physical exam showed a normal posture and gait without an assistive device for ambulation.  The extremities were normal to visual exam.  Exams of the knees, tibias, fibulas, ankles, muscles, motor function, and sensory function were unremarkable.  Provocative diagnostic tests of the knees were negative.  The bilateral knee ROMs are summarized in the chart below.  Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  The diagnosis was listed as residuals of stress fractures of both legs.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB, 2 months prior to separation, rated the right femoral shaft stress fracture condition 10% coded 5022-5003 (periostitis-degenerative arthritis).  
The VA rating decision, 10 months after separation, rated the right lower extremity condition 0% coded 5262 (impairment of tibia and fibula) citing absence of any objective evidence of functional impairment.  The Board found no route to a rating higher than the 10% adjudicated by the PEB.  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 femoral shaft stress fracture condition.

Left Medial Tibial Plateau Stress Reaction Condition.  This stress reaction was a component of the constellation of stress induced changes and fractures.  This condition occurred, simultaneously with the right femoral shaft stress fracture, from increased physical activity in basic training.  The overuse injuries were treated equally and concurrently as a single syndrome.  The history and objective findings for this condition are documented in the preceding section describing the right femoral shaft stress fracture condition.  The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Knee ROM
(Degrees)	MEB ~ 1 Mo. Pre-Sep 	VA C&P ~ 6 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	130	130	140	140	
Extension (0 Normal)	#	#	0	0	
§4.71a Rating	0%	0%	0%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB rated the left medial tibial plateau stress reaction condition 10% coded 5022-5003.  The VARD rated the left LE condition 0% coded 5262 citing absence of objective evidence of functional impairment.  Again, the Board found no route to a rating higher than the 10% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left medial tibial plateau stress reaction 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 femoral shaft stress fracture condition and the left medial tibial plateau stress reaction, 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 20130923, 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 29 May 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their 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:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC