RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00978
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Motor Vehicle Transport Operator, medically separated for “Left Leg Anterior Exertional Compartment Syndrome ” and “Bilateral Tibial Stress Injuries,” rated 20% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant makes no specific contention in his application.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 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 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 PEB - 20090904	VARD - 20100108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Leg Anterior Exertional Compartment Syndrome	7199-7114	20%	Exercise-Induced Compartment Syndrome, Left Lower Extremity (Also Claimed as a Stress Injury)	5299-5262	0%	20091113	
Bilateral Tibial Stress Injuries	5299-5262	0%	Exercise-Induced Compartment Syndrome, Right Lower Extremity (Also Claimed as a Stress Injury)	5299-5262	0%	20091113	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Leg Compartment Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the left leg compartment syndrome began approximately 10 years prior to referral for MEB.  Bilateral leg and ankle X-rays were normal.  A bone scan showed left tibia diffuse stress changes and focal uptake in distal 1/3 of right tibia consistent with grade I (asymptomatic stress reaction on imaging) stress fracture.  At a physical therapy (PT) encounter the CI reported a 10-year history of bilateral leg pain with exertion (running, walking).  He endorsed he had symptoms when previously in the military.  The symptoms had recurred, and worsened, when required to run in his current assignment.  The CI complained that pain started after running about ¾ of a mile and worsened until he stopped.  He reported associated feet tingling, and that symptoms gradually resolved with rest.  The CI consented to running on a treadmill to provoke symptoms.  The physical examination documented a “grossly normal” gait.  The bilateral lower extremity examination revealed tibial tenderness and tense and tender anterior compartments.  There was no tenderness of the proximal tibia or fibula.  The ankle active range-of-motion (ROM) and strength were normal.  The assessment listed non-traumatic compartment syndrome (increased internal pressure in fascia bound muscle group compartments which compromises tissue perfusion and function).  A bilateral lower leg magnetic resonance imaging was normal.  At an orthopedic surgery consultation, the CI reported he had not been doing any significant training for the 4-year period before reenlisting in the service.  He started the routine of company runs, ruck marches, and regular physical training and almost immediately started having pain in both lower extremities.  At the PT evaluation, he could only run 10 to 15 minutes before he developed severe pain and was taken off the treadmill.  The bilateral knee examination revealed lateral deviation of the patellas and mild weakness of the distal quadriceps.  There was no ligamentous instability.  The Lachman (assesses anterior cruciate ligament [ACL]), posterior drawer (assesses posterior cruciate ligament [PCL]), valgus/varus stress (assesses medial collateral ligament [MCL]/lateral collateral ligament [LCL]), and McMurray (assesses menisci) tests were negative.  The assessment listed anterior leg traumatic compartment syndrome.  Orthopedic surgery performed bilateral compartment pressure checks of the anterior, lateral, superficial, and deep compartments.  An orthopedic surgery follow-up documented that the compartment pressure testing was consistent with left anterior exertional compartment syndrome.  The surgeon briefed the surgical option, recommended continued conservative therapy, and the CI opted for conservative therapy.  

The NARSUM, 4 months before separation, recounted the history and interventions.  The CI reported his bilateral leg pain began in basic training during his initial enlistment, and that he remained symptomatic during that service period.  He endorsed treatment with multiple conservative modalities (PT, crutches, nonsteroidal anti-inflammatory drugs [NSAIDs], and temporary profiling) and having numerus imaging studies (X-rays, MRIs, and bone scans) which showed stress injuries and stress fractures.  During his break in service, he reported minimal leg problems as they were always activity related.  Upon reentering active duty, with the requisite increase in physical activity, he experienced recurrence of his lower leg pain.  The bilateral lower extremity examination revealed minimal tenderness of the medial tibial shafts to palpation and left ankle with stress testing.  There was no deformity, edema (excess tissue fluid swelling), or discoloration.  There was no knee laxity and the McMurray tests were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The examiner recounted the findings of the X-rays, MRI, and bone scans.  The diagnosis listed left leg anterior exertional compartment syndrome.  The left knee, bilateral ankle, and bilateral tibia-fibula X-rays were normal.  The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of constant pain involving both shins "as long as impact occurs."  Pain was characterized as aching, sharp, and burning, was made worse by physical activity, and relieved by rest.  The vital signs recorded the CI was 40 pounds above the weight for his ideal BMI [body mass index].  The physical examination documented a normal gait without an assistive device.  The bilateral knee examination revealed normal appearance and function with no tenderness, deformity, edema, effusion (fluid collection), redness, heat, or drainage.  There was no weakness, malalignment, instability, crepitus (grating sound or sensation), locking pain, subluxation, abnormal movement, or guarding of movement.  The Drawer (assesses ACL and PCL), valgus/varus stress, and McMurray tests were negative.  The bilateral knee ROM was flexion of 140 (140 normal) and extension of 0 (0) degrees.  The knees were not additionally limited by pain, weakness, lack of endurance, fatigue, or incoordination with repetitive ROM.  There was no detectable alteration in sensation, form, or function of the bilateral tibia and fibula.  The bilateral ankle examination revealed normal appearance and function with no tenderness, deformity, edema, effusion, redness, heat, or drainage.  There was no weakness, malalignment, instability, abnormal movement, or guarding of movement.  The bilateral ankle ROM was dorsiflexion of 20 (20) and plantar flexion of 45 (45) degrees.  The ankles were not additionally limited by pain, weakness, lack of endurance, fatigue, or incoordination with repetitive ROM.  The bilateral feet did not reveal any sign of abnormal weight-bearing.  Strength, sensation, pulses, and DTRs were normal and pathologic reflexes were absent.  The examiner recounted the findings of the X-rays.  The diagnosis listed left leg anterior exertional compartment syndrome.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered if separate ratings for left leg compartment syndrome and bilateral tibial stress injuries were appropriate in this case, but members agreed that no separately ratable impairment was discernable without violation of VASRD §4.14 (avoidance of pyramiding).  The PEB assigned a 20% rating under an analogous 7114 code (arteriosclerosis obliterans) citing 3/10 pain, 10/10 with prolonged standing, walking, climbing stairs, and impact-type activities, compartment testing compatible with left anterior exertional compartment syndrome, elected conservative treatment rather than the surgical option, symptomatic on walking more than 100 yards, and rated analogous to claudication due to arteriosclerosis obliterans.  The VA assigned a non-compensable 0% rating under an analogous 5262 code (impairment of tibia and fibula) based on the C&P examination 2 weeks after separation, citing exercise-induced compartment syndrome, constant pain in both shins, aching, sharp, and burning pain, precipitated by impact, relieved by rest, no detectable alteration in sensation, form, or function of tibia or fibula, no muscle or bone tenderness, no muscle atrophy, normal knee and ankle ROM without pain, no changes noted with repeated movements, X-ray findings, and a noncompensable evaluation assigned in the absence of malunion of the tibia and fibula with a slight residual knee or ankle disability.  While the CI became symptomatic with physical stressors, symptoms resolved completely when he desisted from the activity and rigors attendant to a military lifestyle.  During his break in service, he reported minimal leg problems, as they were always activity related.  The ROM values in the proximate exams were normal and did not support a minimum rating under the limitation of knee flexion (5260), knee extension (5261), and ankle limited motion (5271) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  There was no ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  The Board recommends no change to the previously assigned rating. 

Bilateral Tibial Stress Injuries.  According to STR and the NARSUM, the bilateral tibial stress injuries began approximately 10 years prior to referral for MEB.  The CI reported his bilateral leg pain began in basic training during his initial enlistment.  The CI presented to the clinic, 3 weeks after returning to active duty, complaining of bilateral tibia and ankle pain.  The examiner documented that he was prior service, and that he had had a 4-year break in service.  The CI reported that he had gain 20 pounds, and had not run, in the intervening 4 years.  He complained of pain only when running.  The physical examination documented an antalgic gait (assuming a gait or posture to lessen pain).  The bilateral lower extremity examination revealed mild tenderness to the mid 1/3 of the tibias.  There was no edema, erythema (redness), or ecchymosis (bruising).  The bilateral ankle active ROM was full and strength was normal.  The assessment listed shin splints.  The plan was for rest, ice, Tylenol, and X-rays.  The work/duty restrictions were “Profile: SHIN SPLINT 844:9 from 28 Jul 2008 to 25 Aug 2008; Comment: No run jump march rucksack X 3 weeks, then run at own pace and duration not to exceed 1 mile X 1 week.”  Bilateral leg and ankle X-rays were normal.  A bone scan showed left tibia diffuse stress changes and focal uptake in distal 1/3 of right tibia consistent with grade I stress fracture.  A bilateral lower leg MRI was normal.  A subsequent bone scan, compared with the earlier scan, showed that the previously seen stress fracture had resolved and that the stress changes persisted.  The NARSUM recounted that bilateral leg pain had begun in basic training during the CI’s initial enlistment.  Historical and contemporary imaging studies had shown stress injuries and stress fractures.  The CI failed conservative management and remained symptomatic during this prior service period.  Symptoms remitted with the relative absence of physical activity during his four year break in service.  He experienced near immediate recurrence of his lower leg symptoms upon reentering active duty.  The bilateral lower extremity examination revealed minimal tenderness to palpation of the medial tibial shafts.  There was no deformity, edema, or discoloration.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The examiner recounted the findings of the X-rays, MRI, and bone scans.  The diagnosis listed bilateral tibial stress injuries.  The left knee, bilateral ankle, and bilateral tibia-fibula X-rays were normal.  The C&P examination recounted the CI complained of constant pain involving both shins "as long as impact occurs."  Pain was characterized as aching, sharp, and burning, was made worse by physical activity, and relieved by rest.  The physical examination documented a normal gait.  There was no detectable alteration in sensation, form, or function of the bilateral tibia and fibula.  Strength, sensation, pulses, and DTRs were normal and pathologic reflexes were absent.  The examiner recounted the findings of the X-rays.  The diagnosis listed bilateral tibial stress injuries. 

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered if separate ratings for bilateral tibial stress injuries and left leg compartment syndrome were appropriate in this case, but members agreed that no separately ratable impairment was discernable without violation of VASRD §4.14 (avoidance of pyramiding).  The Board next considered whether each tibial stress injury remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The Board found that the bilateral tibial stress injuries were not reasonably justified as separately unfitting and therefore there were insufficient grounds for recommending separate leg disability ratings in this case.

The PEB assigned a 0% rating (for the bilateral condition under one rating) using an analogous 5262 code (impairment of tibia and fibula) citing minimal tenderness along medial tibial shafts, full strength, and the disability was not permanent in nature.  The VA assigned a non-compensable 0% rating for the left leg and a non-compensable 0% rating for the right leg under an analogous 5262 code based on the C&P examination.  For the bilateral legs, the VA cited exercise-induced compartment syndrome, stress injury, shin splints, constant pain in both shins, aching, sharp, and burning pain, precipitated by impact, relieved by rest, no detectable alteration in sensation, form, or function of tibia or fibula, no muscle or bone tenderness, no muscle atrophy, normal knee and ankle ROM without pain, no changes noted with repeated movements, X-ray findings, and a noncompensable evaluation assigned in the absence of malunion of the tibia and fibula with a slight residual knee or ankle disability.  While the CI became symptomatic with physical stressors, symptoms and physical findings resolved completely when he desisted from activity.  The ROM values in the proximate examinations were normal and did not support a minimum rating under the limitation of knee flexion (5260), knee extension (5261), and ankle limited motion (5271) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  There was no ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  Members debated if 0% was warranted for the bilateral legs or if application of §4.40 (functional loss) or §4.59 (painful motion) justified a 10% rating.  The Board agreed that the most accurate analogy to both the pathology and disability rating for the bilateral tibial stress injuries is 10%, coded 5299-5262.

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 leg compartment syndrome and the bilateral tibial stress injury conditions.

BOARD FINDINGS:  In the matter of the left leg compartment syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral tibial stress injuries 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.    

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 20140225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160005873 (PD201400978)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA