RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01311
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Supply Clerk) medically separated for a bilateral lower leg disability.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  The CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded to the Physical Evaluation Board (PEB) the bilateral lower leg condition as failing Army retention standards IAW AR 40-501.  Eight additional conditions were identified and forwarded as meeting retention standards, including an adjustment disorder condition.  The Informal PEB adjudicated “bilateral anterior compartment syndromes (shin splints) evaluated as muscle injury, Group XII muscles” as unfitting, rated 10% for each leg, 20% combined, including the bilateral factor, citing rating criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting, with the exception of the referred adjustment disorder.  The PEB found this condition as non-compensable, although it could be administratively unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contended for her Posttraumatic Stress Disorder condition.  Her complete submission is at Exhibit A.

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 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:    

 IPEB - Dated 20090106	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Anterior Compartment Syndromes	5399-5312	20%**	Residuals, Right Tibia Stress Fractures	5010-5262	10%	20090216	
			Residuals, Left Tibia Stress Fractures	5010-5262	10%	2009216	
Other MEB/PEB Conditions x 8 (Not In Scope)	Other x 18	
RATING:  20%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20060526 (most proximate to date of separation (DOS)).  
** Adjudicated by PEB as two separate disabilities (recognizing separately unfitting conditions in the right and left lower extremities), with resultant combined disability, including bilateral factor, equivalent to 20% disabling.

ANALYSIS SUMMARY:  

Bilateral Anterior Compartment Syndrome.   The narrative summary dated 17 October 2008, approximately 3 months before separation, noted the CI’s history of non-traumatic bilateral lower extremity pain and shin splints with onset in early 2007.  She initially had pain with running that increased in frequency and intensity over time.  By June 2007, the CI was no longer able to run due to leg pain.  At this point her pain included both knees; however, the left has always been worse than the right.  She also had hip pain.  In the summer of 2008, the CI began experiencing neuropathic symptoms of pins and needles sensation located in both lower extremities, traveling distally to include both feet and toes.  The CI underwent consultations with physical therapy, orthopedics and neurology.   The orthopedic prescribed orthotics and she was given non-steroidal anti-inflammatory medications without significant improvement in symptoms.  At the follow-up orthopedic visit in July 2008, the physician noted recent bone scan suggested that she had some worsening (scans shows overuse syndrome) despite significant modification of activities.  The diagnosis of chronic bilateral lower extremity pain secondary to overuse syndrome was made and the physician noted that despite significant alteration in physical activities, and attempts to rehabilitate, the CI no longer meets retention standards.  Electromyography (EMG) of the lower extremities in August 2008 was abnormal (decreased conduction in the femoral nerve distribution).  The neurologist indicated that there was no clinical evidence of loss of muscle motor or sensory function.   At the NARSUM, the CI reported she has bilateral knee pain that is constant, intense and burning in nature, and there is constant sensation of pins and needles in the lower extremities, aggravated by running, jumping, walking for greater than ½ mile or standing for greater than 15 minutes. The examiner recorded the result of the July 2008 orthopedic physical exam that documented pain to palpation in the mid-anterior tibia and in the medial and lateral femoral condyles of both knees.  There was no evidence of neurovascular compromise in either extremity, and the ankles showed no signs of instability.  The range of motion (ROM) recorded at the MEB physical was documented as “full” for the knees and ankles, and there was no evidence of infection or inflammation.  Tenderness to palpation in both legs was noted and the CI was able to heel and toe-walk with pain in both extremities.  Muscle strength was normal bilaterally.  The examiner recorded the diagnosis of bilateral lower extremity pain secondary to chronic bilateral tibial stress reactions with fracture and bilateral foraminal neuropathies at the inguinal ligaments, and noted that her condition is chronic in nature, without improvement, and surgery is not indicated.  It was noted that she has flare ups of intense pain in the left knee; however, there is no associated fatigue, weakness, lack of endurance, instability or incoordination. The physician opined that the CI is non-deployable due to her inability to wear body armor.  At the VA Compensation and Pension (C&P) exam, a month before separation, the physical examination noted absence of atrophy, no evidence of impaired coordination of the lower leg.  ROM of right and left knees and ankles were normal.  Painful motion was documented and De Luca criteria were not present.  Neurological examination of the lower extremities documented normal motor and sensory function. 
The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated each extremity at 10% under the analogous code 5399-5312 (anterior muscles of the leg) and cited “moderate injury which contains consideration for the nerve involvement.”  The Board opined that Mild impairment under the muscle code corresponds to a 0% evaluation and 10% reflects moderate degree of impairment. The Board noted with the exception of the extensor muscles of the hip, all muscle group codes corresponding to the lower extremity rates moderate impairment at 10%.  The VA rated each lower extremity at 10% coded analogously 5010-5262 for functional loss.  All Board members agreed that the 10% criteria were met.  A higher rating under the muscle codes requires documented evidence that the condition demonstrated impaired muscle function of moderately severity (prolonged infection, sloughing of soft parts, and intermuscular scarring); not supported by the record at hand.  At the time of separation from service, the NARSUM noted that both knees and ankles had full ROM.  Therefore, neither knee nor ankles were compensable under the ROM codes 5260, 5261, and 5271 respectively.  The Board next considered the nerve codes 8526 (femoral) and 8527 (internal saphenous); however, the use of these code are not supported by the evidence since there is no evidence of ratable peripheral neuropathy, such as muscle atrophy, weakness, loss of sensory function, and incapacitating episodes.  Therefore, the Board concluded there was no evidence in the treatment record that would support a rating greater than 10% for each extremity.  There were no additional codes applicable for consideration.  Thereupon, 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.  

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 bilateral anterior compartment syndrome condition, 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 20140308, 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 XXXXXXXXXX, AR20160003985 (PD201401311)

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