RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01034
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090812

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “bilateral non-traumatic compartment syndrome of lower legs,” with a disability rating of 20%.

CI CONTENTION:  He was given additional and higher ratings for his conditions by the VA and was not evaluated for PTSD.  The CI’s 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 based on 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 - 20090724	VARD - 20091202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Non-Traumatic Compartment Syndrome of  Lower Legs	5299-5262	20%	Compartment Syndrome, Left Lower Leg	5311	10%	20091022	
			Compartment Syndrome, Right Lower Leg	5311	10%	20091022	
Remote Stress Fractures of the Tibia	Not Unfitting	Residuals, Left Tibial Stress Fracture	5299-5262	0%	20091022	
		Residuals, Right Tibial Stress Fracture	5299-5262	0%	20091022	
Headache Syndrome	Not Unfitting	Tension Headaches	8199-8100	0%	20091022	
Knee Pain	Not Unfitting	Retropatellar Pain Syndrome, Left Knee	5299-5024	10%	20091022	
		Retropatellar Pain Syndrome, Right Knee	5299-5024	10%	20091022	
Lower Back Pain	Not Unfitting	Lumbar Strain	5237	10%	20091022	
Obstructive Sleep Apnea	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20091022	
Anxiety Disorder NOS	Not Unfitting	Post-Traumatic Stress Disorder	9411	50%	20991104	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Bilateral Non-traumatic Compartment Syndrome of Lower Legs.  According to the service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI began having bilateral lower extremity pain about 6 months into his 2007-2008 deployment to Iraq and was diagnosed with bilateral compartment syndrome.  Upon re-deployment, orthopedics reconfirmed this diagnosis.  Radiographic studies demonstrated normal lower right and left legs without evidence of fracture, inflammation or neoplastic changes.  In February 2009, the CI underwent a right lower extremity fasciotomy without complications.  He healed from the surgery, however, his pain continued and it was opined that surgery on the left lower extremity would be of no benefit to the CI.  Despite treatment, the bilateral lower extremity condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “bilateral non-traumatic compartment syndrome of the lower extremities” for PEB adjudication.

At the MEB NARSUM examination on 13 July 2009, 1 month prior to separation, the CI reported pain in both legs during exertion.  Rapid or prolonged walking or any attempts at running caused severe pain.  Physical examination of the lower extremities revealed tenderness only in the anterior compartment of the legs bilaterally.  A surgical scar was noted to be well-healed and not disfiguring, but was tender on deep palpation.  No sensory deficits or vascular compromise were documented.  The CI’s knee range of motion (ROM) demonstrated flexion to 145 degrees (normal 140) without pain and extension to 0 degrees (normal).  Recorded ROMs for each ankle were dorsiflexion to 25 degrees (normal 20) and plantar flexion to 45 degrees (normal). 

At the VA Compensation and Pension (C&P) examination on 22 October 2009, performed 2 months after separation, the CI reported he had received no further evaluations or treatment for his condition and that his pain had remained stable.  Physical examination showed tenderness to palpation over the anterior lateral compartment in both lower legs, and a non-tender surgical scar on the right.  Neurological and motor functions were intact bilaterally.  Recorded ROM was flexion to 140 degrees and extension to 0 degrees of extension in both knees, without pain, weakness, fatigability or incoordination upon repetition.   Both knees were stable and the CI had a normal gait.  He was able to heel and toe walk, squat and arise, and stand on a single leg, without evidence of instability.  

The Board directed attention to its rating recommendation based on the above evidence.  As noted previously, the PEB demonstrated the intention of invoking §4.40 (functional loss, pain on use) for each extremity, and combined the separate 10% ratings to arrive at a 20% rating for the bilateral lower leg non-traumatic compartment syndrome under the analogous code 5299-5262 (tibia and fibula, impairment of), citing pain. The VA assigned a 10% rating for each leg separately under the analogous 5299-5024 (tenosynovitis) code for pain.  There was no evidence of moderate knee or ankle disability to justify a higher rating under the 5262 code, and no path to a higher rating under the 5024 code.  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 bilateral lower extremities condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the remote stress fractures of the tibia, headache syndrome, knee pain, lower back pain, obstructive sleep apnea (OSA), and anxiety disorder not otherwise specific (NOS) conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board reviewed the stress fracture condition and noted that the CI had a history of bilateral tibia stress fractures during basic training which healed without residuals.  The CI was diagnosed with headache syndrome in 2007 and had a negative CT scan; treatment records for this condition were silent thereafter.  The Board next considered the knee pain, low back and OSA and found no documented evidence that these conditions interfered with satisfactory duty performance.  Review of the available records regarding knee pain showed reports of pain, however, the MEB and C&P examinations documented normal knees and ROM without painful motion.

The Board noted that the CI underwent an MEB mental health (MH) examination a month before separation and was diagnosed with anxiety disorder NOS.  The examiner documented anxiety and some mild trauma-related symptoms, but these were stable.  The examiner opined that these symptoms were consistent with anxiety disorder NOS in partial remission, and that his condition met retention standards.   It was also noted he met criteria for this diagnosis and no other MH condition.  

The remote stress fractures of the tibia, headache syndrome, knee pain, low back pain, OSA, and anxiety disorder NOS conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bilateral non-traumatic compartment syndrome of lower legs condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended remote stress fractures of the tibia, headaches, knee pain, low back pain, OSA, and anxiety disorder NOS conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

DROP v13                                                Enclosure (2) 

Use appropriate chart from the Nine Core Condition Templates

DOS 200#####
Left Hip (Thigh) ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Flexion (125 Normal)	#	#	#	
Extension (20)	#	#	#	
External Rotation (45)	#	#	#	
Abduction (0-45)	#	#	#	
Adduction (45)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

DOS 200#####
Right Elbow ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Flexion (145 Normal)	#	#	#	
Extension (0)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

DOS 200#####
Left Wrist ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Dorsiflexion (70 Normal)	#	#	#	
Palmar Flexion (80)	#	#	#	
Ulnar Deviation (45)	#	#	#	
Radial Deviation (20)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

DOS 200#####
Right Forearm ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Pronation (80 Normal)	#	#	#	
Supination (85)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

Other Table Examples:  

DOS 200#####
Pulmonary Exam	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
FEV1 (% Predicted)	#	#	#	
FEV1/FVC	#	#	#	
Meds				
§4.97 Rating	#%	#%	#%	

DOS 200#####
Right / Left  Hand
(Dominant)	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Thumb to Fingertips
(Distance, inches)			
Index to Palmar Crease
(Distance, inches)			
Index Extension
(Degrees)			
Middle to Palmar Crease
(Distance, inches)			
Middle Extension
(Degrees)			
Comments	AO	AO	
§4.71a Rating	#%	#%	

DOS 200#####
HEARING	EXAM	MEB  ~5 Mo. Pre Sep	VA C&P ~2 Mo. After Sep	
LEFT EAR	Average Hearing Loss	 dB	 dB	
	Speech Discrimination	%	%	
	Table VI / VIa	  / I	 / I	
RIGHT EAR	Average Hearing  Loss	 dB	 dB	
	Speech Discrimination 	%	%	
	Table VI / VIa	 / I	  /  I	
§4.85 RATING	Table VII	%	%	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four)

Example from case     DOS 200#####
HEARING	EXAM	MEB  ~5 Mo. Pre Sep	VA C&P ~2 Mo. After Sep	
LEFT EAR	Average Hearing Loss	53 dB	48 dB	
	Speech Discrimination	88%	92%	
	Table VI / VIa	II / III	I / II	
RIGHT EAR	Average Hearing  Loss	53 dB	45 dB	
	Speech Discrimination 	88%	94%	
	Table VI / VIa	I / III	I / II	
§4.85 RATING	Table VII	0%	0%	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four)

DROP v13                                                Enclosure (3)

§4.130 Rating:  

70% > Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood 
		1) suicidal ideation 
		2) obsessional rituals which interfere with routine activities
		3) speech intermittently illogical, obscure, or irrelevant
		4) near-continuous panic or depression affecting the ability to function
		independently, appropriately and effectively
		5) impaired impulse control (such as unprovoked irritability with periods of 				violence)
6) spatial disorientation		    7) neglect of personal appearance and hygiene
		8) difficulty in adapting to stressful circumstances (including work or a work like 			setting)
		9) inability to establish and maintain effective relationships

50% > Occupational and social impairment with reduced reliability and productivity
		1) flattened affect
		2) circumstantial, circumlocutory, or stereotyped speech
		3) panic attacks more than once a week
		4) difficulty in understanding complex commands
		5) impairment of short- and long-term memory (e.g., retention of only highly 				learned
		 material, forgetting to complete tasks)
		6) impaired judgment
		7) impaired abstract thinking
		8) disturbances of motivation and mood
		9) difficulty in establishing and maintaining effective work and social 				relationships

30% > Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal)
		1) depressed mood
		2) anxiety
		3) suspiciousness
		4) panic attacks (weekly or less often)
		5) chronic sleep impairment
		6) mild memory loss (such as forgetting names, directions, recent events) 

10%> Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication

DROP v13                                                Enclosure (4)

Awaiting Updates

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160009948 (PD201401034)

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