RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02642
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Radio COMSEC, medically separated for leg condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic left knee pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (“right shoulder tendonitis,” “left foot plantar fasciitis,” and “sensorineural hearing loss”) for PEB adjudication.  The Informal adjudicated “tibial impairment (stress fracture)” unfitting, rated 10%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Tibial Impairment (Stress Fracture)”

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 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:  

IPEB - Dated 20080724	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Tibial Impairment (Stress Fracture)	5262	10%	Stress Fracture, Left Tibia…	5262	20%	20090121	
Other MEB/PEB Conditions x 3 (Not In Scope)	Other x 9 (Not in Scope)	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090121 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Tibial Impairment (Stress Fracture) Condition.  The service treatment record (STR) indicated the CI initially presented on 26 November 2007 with intermittent left leg pain located over the shin for 8 weeks, which was aggravated by exertional exercises.  Treatment consisted of ibuprofen, a nonsteroidal anti-inflammatory drug.  A stress fracture was considered and X-rays revealed focal periosteal (a layer around the bone) elevation in the posterior proximal tibia.  A bone scan on 6 December 2007 demonstrated a Grade 4 stress fracture of the proximal left tibia and stress-related changes of the knees.  After 5 weeks of rest, the CI began running again and felt pain in the left mid-shin area.  An additional 30 days without running or jumping was instituted along with physical therapy.  A repeat bone scan on 10 March 2008 revealed a healing stress fracture of the proximal left tibia and no evidence of an acute injury.  However, tibia pain worsened rather than improved and left retropatellar (behind the knee cap) pain, which began around the same time as the tibia pain, was worse with standing after prolonged periods, sitting, and ascending and descending stairs.  Examination of the left knee in April 2008 revealed no swelling or effusion, mild tenderness to palpation over the patellar (knee cap) tendon, and a full range-of-motion (ROM) without crepitus (grinding sensation) or instability, or pain with McMurray testing (to determine meniscal involvement).  A positive patellar grind test was consistent with patellofemoral dysfunction.  Additionally, there was tenderness to palpation over the medial proximal third of the tibia.  An X-ray series of the knees dated 17 June 2008 was normal.  On 26 June 2008, the CI noted left knee joint pain in the medial aspect anteriorly accompanied by a popping sound, worse with weight bearing.  On examination knee appearance and motion were normal, but pain was elicited by motion.  Meloxicam, a nonsteroidal anti-inflammatory drug, was prescribed for the stress fracture pain.

The commander’s statement dated 17 June 2008 indicated the CI could not perform his duties due to profile restrictions, which were addressed in the permanent L3 profile issued on 25 June 2008 for chronic left knee pain due to a stress fracture and a permanent U2 profile for right shoulder tendinitis, which is not in scope.  The limitations included no military functional activities except wearing a protective mask and chemical defense equipment and no running, push-ups, alternative physical fitness testing, or standing for more than 5 minutes.  The CI reported at the MEB examination on DD Form 2807-1 dated 18 June 2008 that he had pain in the left knee and a stress fracture in the proximal tibia of the left leg.  The MEB physical examiner noted on DD Form 2808 dated 26 June 2008 slightly decreased flexion of the left knee.   

The MEB narrative summary (NARSUM) dated 8 July 2008 and based on a physical examination performed on 26 June 2008 noted the CI’s left knee pain began in October 2007 after physical activity such as ruck marches and running.  A stress fracture of the left proximal tibia and stress related changes of the knees were found on a bone scan in December 2007.  Physical therapy and home exercises afforded no relief nor did pain medications.  On examination there was a decreased ROM of the left knee secondary to pain only and not limited by weakness, fatigue, lack of endurance or incoordination.  There was no instability, meniscal involvement, medial or lateral joint line tenderness, or tenderness in the popliteal fossa (back of the leg posterior to the knee).  There was mild tenderness to palpation around the patella and as per orthopedics, a positive patellar grind and negative Lachman (to test for instability).  There was no atrophy or fasciculation (muscle twitching).  The right knee was normal.  The ROM measurements were flexion 120 degrees (Normal 140 degrees) and extension 2 degrees (Normal 0 degrees) with no change in the ROMs after repetition.  The CI was unable to meet the physical demands of the Army since his pain became progressively worse with prolonged standing and walking and he could not do any running or impact activities.  

At the VA Compensation and Pension (C&P) examination dated 11 December 2008, performed 3 months after separation, the CI reported the stress fracture of the left leg healed, but he continued to have left proximal tibial pain described as aching and burning.  It was worse with activity including standing and walking and he was unable to run or participate in high impact activities.  Left knee pain began while performing a 2-mile PT run in the absence of a specific injury and he had daily burning knee pain located along the joint line without swelling or instability.  The CI had no treatment or used assistive devices at the time of the VA examination and had no flares.  Examination of the left leg below the knee was normal in appearance without deformity, but was tender to palpation along the entire medial (inner) aspect of the tibia from the ankle to the knee.  There was no deformity, quadriceps atrophy, or effusion of the left knee; however, there was tenderness along the medial joint line.  The ROM measurements were flexion 140 degrees and extension 0 degrees with pain between 120-140 degrees of flexion with no limitation of motion following repetition.  There was no laxity, crepitus, or meniscal involvement and neurologic examination was unremarkable.  

The Board directed its attention to its rating recommendation based on the above evidence.  The IPEB assigned a 10% rating using code 5262 (Tibia and fibula impairment) for tibial impairment (stress fracture) and was rated for mild knee impairment.  The VA assigned 10% rating using code 5257 (Knee impairment-recurrent subluxation or lateral instability or pain on motion according to the VARD) for left knee strain (which was reduced in 2009 to 0% due to a clear and unmistakable error by pyramiding IAW VASRD §4.14) and a 10% rating using code 5262 for the stress fracture of the left tibia.  The Board sought a route for a higher rating and considered a 20% rating for moderate knee disability; however, in the absence of ankylosis, laxity (contrary to the VA use of code 5257), meniscal involvement, a more limited ROM of either flexion or extension, or with weakness and insecurity in weight-bearing objectively demonstrated, the Board was unable to find a route.  Alternatively, use of analogous code 5099-5003 (degenerative arthritis) with a 10% rating was considered, but does not offer any additional benefit to the CI.  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 tibial impairment (stress fracture) 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 tibial impairment (stress fracture) 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.  

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 20140529 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, AR20160003689 (PD201402642)

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