RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX  	CASE:  PD-2014-01858  
BRANCH OF SERVICE:  marines  	SEPARATION DATE:  20040430  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Engineer Equipment Operator) medically separated for a chronic back condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  The CI was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “grade 1-2 spondylolisthesis with dysplastic pars” condition was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (bilateral medial tibial periostitis) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “Grade 1/2 L5-S1 spondylolisthesis with dysplastic pars” as unfitting, rated 10% with application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting, Category III, (conditions that are not unfitting and do not contribute to the unfitting condition).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI requested that the Board review all conditions.  The 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 20040226	VA* -  based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Grade 1/2 L5-S1 Spondylolisthesis with Dysplastic Pars	5239	10%	Spondylolisthesis	5239	0%	STR	
Bilateral Medial Tibial Periostitis	Category III
Not Unfitting	Not Considered	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20050617 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  

L5-S1 Spondylolisthesis with Dysplastic Pars Condition.  In the narrative summary (NARSUM), the CI reported the atraumatic onset of activity-related low back pain that began when doing heavy construction on a deployment.  The pain radiated to the buttock and lateral thigh areas down to the knee level, with more recent radiation on the right to the lateral calf area.  Treatment included an extensive course of physical therapy (PT), anti-inflammatory medications, and a lumbar support brace.  The CI reported that the pain was constant, leading to intolerance of any work-related activity and some difficulty with activities of daily living such as dressing and undressing.  

At an orthopedic appointment on 31 July 2003, the CI described the current back pain as “everyday stuff.”  On examination the CI had tenderness to the paralumbar area, normal (5/5) strength of first toe extension, “OK” sensation, and good lumbar range of motion (“fingers - floor”).  At a primary care visit on 7 August 2003, the CI had mild tenderness to palpation of the lower back, full range-of-motion (ROM) and normal (5/5) strength.  At a PT consult on 25 August 2003, the CI had “increased flexibility” of the trunk, and normal active ROM and strength of the lower extremities.  At a primary care visit on 22 September the CI had intact sensation, normal (5/5) strength, and “↑ pain [after] full ROM.”  Magnetic resonance imaging (MRI) of the lumbar spine on 24 September 2003 showed minimal central disk bulge and annular protrusion at L5-S1 without impingement on the spinal sac or associated neural foraminal stenosis (narrowing of the nerve outlet pathway).  At a primary care visit on 2 October 2003 the CI complained of numbness of both feet; on examination there was normal sensation and strength and “↑ pain during & [after] full ROM.”  The following day, the CI noted low back pain radiating down the legs and numbness and tingling of the feet and toes.  On examination, there was tenderness to palpation of the lumbar region and “full ROM [with] mild pain.”  

At an orthopedic appointment on 6 October 2003, the CI complained of low back pain (LBP) which radiated to the buttocks, hips, thighs, and right calf.  The CI also complained of numbness/tingling of both feet.  Recent X-rays had shown L5-S1 spondylolisthesis (forward displacement of the L5 vertebra on the one below it [S1], which could cause pain by compression of nerve roots) with dysplastic pars (bony deformity).  On examination, there was decreased forward flexion (fingers above knee) and decreased extension, decreased sensation to light touch in a stocking-glove distribution from the distal thighs to the feet (usually associated with peripheral nerve issues), and slight (4+/5) decreased strength of the ankles in a non-dermatomal pattern (area of skin supplied by cutaneous branches of a single spinal nerve; neighboring dermatomes can overlap).  

The DD Form 2808, Report of Medical Examination, was accomplished on 25 November 2003 (5 months pre-separation), and showed limited ROM of the spine due to pain.  The NARSUM examination was accomplished on 1 December 2003 (5 months pre-separation) and showed paralumbar tenderness to palpation; diminished lumbar flexion with the ability to reach above the knees only; diminished lumbar extension; diffuse, mildly diminished strength with manual muscle testing of muscle groups of the right leg which was nondermatomal and not confined to a single nerve root distribution.  There were paresthesias with light touch in a stocking-glove type distribution from the distal thigh to the foot area bilaterally.  

The VA conducted a Compensation & Pension (C&P) examination of the back on 7 February 2012 (almost 5 years post-separation).  However, Board members ascertained that this exam was so distant from the date of separation that it had little probative value in the rating determination.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10%, coded 5239 (Spondylolisthesis).  The VA rated the condition at 0% (based on the STR) and coded 5239, citing noncompensable ROM and listing the requirements for a 10% rating.  Although there was not a full, VA-compliant examination of the back available proximate to separation to determine a VA disability rating, there were many annotations that the CI had full, but painful, ROM of the back or thoracolumbar spine, which would support a rating of 10%.  No entries supported or suggested a rating higher than 20% based on ankylosis, ROM, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or physician-prescribed bed rest.  

The Board considered whether additional rating could be recommended under a peripheral nerve code for the associated radiculopathy in evidence at separation.  Although the CI did have complaints of numbness or tingling in the feet, examinations revealed normal sensation or decrease in a stocking-glove distribution, and strength was normal or slightly (4+/5) decreased in a nondermatomal fashion, not suggestive of radicular nerve involvement.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The intermittently documented sensory component in this case had no functional implications, and no objective motor weakness was in evidence.  There was thus no evidence of significant functional impairment from the associated radiculopathy, and the Board could not support a recommendation for additional disability rating on this basis.  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 L5-S1 spondylolisthesis condition.  

Contended PEB Condition.  

Medial tibial stress syndrome (MTSS; also called shin splints, tibial stress syndrome, and periostitis) is a benign, though painful, condition, and a common problem in the running athlete.  It is prevalent among military personnel, runners, and dancers, showing an incidence of 4% to 35%.  The exact cause of this condition is unknown.  The most proven risk factors are hyperpronation of the foot, female sex, and history of previous MTSS.  Conservative treatment is almost always successful and includes several options; though none has proven more superior to rest.  Prevention programs do not seem to influence the rate of MTSS, though shock-absorbing insoles have reduced MTSS rates in military personnel, and ESWT [extracorporeal shock wave therapy] has shortened the duration of symptoms.  [“Medial tibial stress syndrome.” Clin Sports Med. 2012 Apr;31(2):273-90.  http://www.ncbi.nlm.nih.gov/pubmed/22341017]  

The STR detailed that the CI was seen intermittently for bilateral anterior and medial tibial pain beginning in April 2002 (pain began 3-4 weeks earlier).  The onset was described as gradual and associated with running, jumping, marching, and walking, but no specific injury.  Workup included normal X-rays of the pelvis and bilateral tibias.  

The CI was seen in PT clinic on 6 May 2002, and stated that the pain had resolved 80%.  The CI was able to squat and hop on each leg 10 times without pain, was observed to have normal gait, and jogged three laps around the gym without symptoms.  The diagnosis was resolving stress reactions bilateral mid-tibias, and the plan was to continue a profile for 7 days and then return to duty.  The CI was seen in primary care on 19 March 2003, complaining of shin splints and right ankle pain (note that the “shin” is the anterior border of the tibia).  The shin pain was recurrent while the right leg pain was new.  There was full ROM and normal strength, but tenderness bilaterally on the medial tibias.  The diagnosis was shin splints and the treatment was limited duty for 30 days, anti-inflammatory analgesics, and referral to PT.  At the PT evaluation a week later, it was noted that the CI had previously been treated at PT from February to June 2002.  The current history was “recurrent [bilateral] shin pain x 2-3 weeks ago.  Running in boots, feels pain during running around the first mile pain starts.”  On examination, there was normal gait, pes planus (flat feet) bilaterally, normal strength of the lower extremities, and tenderness of the “tibialis” (not clear if this referred to the tibial bone or the anterior tibialis muscle).  The expectation was that the CI would be able to run without pain in four weeks.  A bone scan showed no stress fractures or other abnormalities.  

The CI was seen in primary care on 4 June 2003 (3 weeks prior to returning to CONUS) and was able to do limited runs without symptoms, but had not run over 0.5 miles.  The examiner stated, “[The CI] Thinks he can rehab himself in time to be full duty prior to that [returning to CONUS].”  The CI was evaluated by a civilian orthopedist on 1 July 2003 and had tenderness along the posteromedial border of the mid-tibia bilaterally, significant hyperpronation of the lower extremities, and no pain with resisted foot or ankle motions.  The diagnosis was bilateral medial tibial stress syndrome secondary to hyperpronation.  

At a primary care visit on 25 July 2003, 9 months pre-separation, the CI complained of leg pain with running and occasionally with walking; on examination there was tenderness of both shins.  At an orthopedic appointment a week later (31 July 2003), the CI complained of bilateral shin pain that worse than the back pain.  There was normal strength and sensation of the lower extremities, and tenderness diffusely over the medial tibias and the lateral muscle compartments.  Low impact cardiovascular exercise was prescribed for both the back and tibial conditions.  An Abbreviated Limited Duty Medical Board Report (NAVMED 6100/5) was accomplished on 25 August 2003 for limited duty, for a period of eight months.  The listed diagnoses were low back pain and bilateral medial tibial periostitis.  

At a primary care appointment on 3 October 2003, the CI complained of back pain and numbness and tingling in his toes, but no other symptoms of the lower extremities.  At an orthopedic appointment on 6 October 2003, the CI’s chief complaint was LBP with numbness/tingling of both feet, and the exam focused on the back.  The final diagnosis referred to the back, and the CI was referred to the PEB without any reference to a lower extremity condition.  

The DD Form 2807-1, Report of Medical History, was accomplished on 5 November 2003, 5 months pre-separation, and the CI described his back problems in depth, but answered “No” to other questions about the lower extremities.  After reviewing the form, the examiner discussed the back condition and stated, “[Patient] states he is in good health other than his back problem.”  In the accompanying physical examination (DD Form 2808), the examiner annotated “Normal” for the evaluation of the lower extremities and feet.  On the DD Form 2697, Report of Medical Assessment, the CI described the back problems without any reference to leg problems, and the examiner stated, “[Patient] states he is in good health other than his complaints about his LBP.”  At a PT appointment on 19 November 2003, the CI stated that he was being asked to go to the field “against his medical board,” and voiced concerns about pain control issues, but only back pain (not tibial pain) was discussed.  

The NARSUM was accomplished on 1 December 2003 (4 months pre-separation), and it was noted that the CI’s leg pain was located in the lateral as well as distal medial leg, and had varied in intensity over time.  Examination of both legs revealed diffuse tenderness to palpation over the medial tibia as well as lateral compartments; all compartments were soft.  There was pain with resisted inversion, plantar flexion, and eversion.  The examiner stated, “It has been recommended that he avoid running, jumping, field exercises, lifting more than 20 pounds, operation of heavy equipment, standing, and the ambulation of greater than 30 minutes duration” – without clarification whether these restrictions were due to the tibial periostitis, or solely due to his back condition.  

In a non-medical assessment to the hospital commander (for the MEB) on 28 January 2004 (3 months pre-separation), the CI’s commander stated, “Due to his back problems SNM [the CI] cannot conduct his duties as a Heavy Equipment Operator,” without any reference to the leg conditions.  

The VA conducted a C&P examination of the knee and lower leg on 7 February 2012 (almost 5 years post-separation).  However, Board members ascertained that this exam was so distant from the date of separation that it had no probative value in the fitness determination.  

The Board directed attention to its recommendation based on the above evidence.  The CI had the onset of bilateral periostitis (shin splints) in March 2002, 5 months after entry onto active duty and 2 years prior to separation.  The intensity of the pain varied over time, and was exacerbated by increased activity.  Reporting of MTSS symptoms decreased after institution of limited duty in August 2003 (as would be expected), and were not discussed in the last few clinical notes prior to separation, the DD 2808, the DD 2697, or the commander’s non-medical assessment.  The STR is consistent with a contention that the MTSS responded to conservative treatment (i.e., rest and modified activity), and was not unfitting at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, Board consensus was that there was insufficient cause to recommend a change in the PEB fitness determination the tibial periostitis and so no additional disability ratings are recommended.  

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 L5-S1 spondylolisthesis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral medial tibial periostitis condition, the Board majority recommends no change from the PEB determination as not unfitting.  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 20140501, 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 6 Jan 16

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

					XXXXXXXXXXXXXXX
	     				Assistant General Counsel
					(Manpower & Reserve Affairs)