RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02793
BRANCH OF SERVICE:  Army	BOARD DATE:  20150630
SEPARATION DATE:  20090725

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Infantryman) medically separated for bilateral anterior compartment syndromes.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “bilateral exercise induced compartment syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (bilateral knee pain, chronic low back pain [LBP], quadriceps tendinitis, and cervical pain) for PEB adjudication.  The Informal PEB adjudicated “bilateral anterior compartment syndromes evaluated as muscle injury, Group XII muscles” as unfitting, rated 20%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 20090526	VA* - (~13 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Anterior Compartment Syndromes Evaluated as Muscle Injury, Group XII Muscles	5399-5312	20%	Left Lower Extremity Compartment Syndrome to include Muscle Aches and Swollen Joints	8599-8522	20%	20100902	
			Left Lateral Lower Extremity Scar Associated with Left
Lower Extremity Compartment Syndrome to include Muscle Aches and Swollen Joints	7804	10%	20100902	
			Left Lower Extremity Peripheral Neuropathy	8521	NSC	20100902	
			Right Lower Extremity Compartment Syndrome to
Include Muscle Aches and Swollen Joints	8599-8522	20%	20100902	
			Right Lateral Lower Extremity Scar Associated with Right Lower Extremity Compartment Syndrome to Include Muscle Aches and Swollen Joints	7805	0%	20100902	
			Right Lower Extremity Peripheral Neuropathy	8521	NSC	20100902	
Bilateral Knee Pain	Not Unfitting	Left Knee	5260	NSC	20100902	
		Right Knee	5260	NSC	20100902	
Chronic Low Back Pain	Not Unfitting	Lumbar Spine (Lower Back)	5242	NSC	20100902	
Quadriceps Tendinitis	Not Unfitting	Right Quadriceps Tendonitis	5023-8526	Deferred	20100902	
		Left Quadriceps Tendonitis	5023-8526	Deferred	20100902	
Cervical Pain	Not Unfitting	Cervical Spine (Neck) Degenerative Changes	5010-5242	20%	20100902	
Other x 0 	Other x 8	
RATING:  20%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20101223 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board notes that the PEB listed a diagnosis of bilateral anterior compartment syndrome (CS) on the DD Form 199, but provided a 10% rating for an unfitting right CS and 10% for an unfitting left CS, with a combined rating for the two lower extremity (LE) conditions of 20%, with the bilateral factor noted.  Therefore, following the introduction the conditions of left and right CS are addressed individually.

Introduction Bilateral Anterior CS.  The narrative summary (NARSUM) notes the CI developed bilateral LE pain during a road march in January 2008.  The CI was diagnosed with bilateral CS.  An orthopedic note on 15 July 2008 indicated that electrodiagnostic studies (EMG/NCV) showed “focal denervation of the peroneal nerve affecting part of the anterior tibialis and EDB [extensor digitorum brevis] nerve branch.”  The CI underwent bilateral compartment release on 5 August 2008 and the operative note indicated that there was significant scarring of the superficial peroneal nerves, right greater than left.

Right CS Condition.  The post-operative course of the right LE following the compartment release surgery during was uneventful.  The CI reported some calf pain, tightness, and numbness, but serial exams were normal, with soft, non-tender calf and anterior leg, with normal strength, sensation, and pulses noted.

At the MEB examination on 25 March 2009, 4 months prior to separation, the CI reported bilateral LE pain, left greater than right, aggravated by weight bearing activities.  The MEB physical exam noted a mild limp and normal strength of the right LE (RLE).  At the VA Compensation and Pension (C&P) examination on 2 September 2010, 13 months after separation, the CI reported bilateral LE swelling, pain, weakness, fatigability, and sensory disturbance down the lateral aspect of the calves, with weakness of the foot aggravated by weight bearing.  He reported daily use of nerve pain medication and as needed use of pain medication.  The CI reported that he “trips easily” and that the symptoms were worse as he was trying to increase his activity level and that at times the “anterior leg” got so tight he would have trouble lifting his foot.  He also reported that at times he used a cane.  The CI noted that since the surgery he had pain and a burning sensation in the front of his legs and the bottom of his foot.  The VA examiner noted the effect of the nerve symptoms was “rare nerve pain with use of…medication.”  The exam noted a normal gait.  There was a non-tender scar of the RLE and muscle strength was 5/5, without atrophy or spasm noted, but toe walking was noted to be “with difficulty” due to “LE weakness.”  Sensation was decreased to light touch and pinprick on the outside of the calf, with normal RLE reflexes and pulses and exam of the foot was normal.  The examiner noted that there was no tenderness to palpation, bruising, swelling, or deformity of the anterior tibia.  EMG on 16 March 2009 showed no active nerve injury, but noted evidence of prior nerve injury of the anterior tibialis and EDB nerves as previously noted on the pre-operative EMG.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right CS 10% coded as 5399-5312 (analogous to Group XII muscle injury) an analogous code for CS.  The VA rated the right CS 20%, coded 8599-8522 (analogous to severe incomplete paralysis of the superficial peroneal nerve).  The Board first noted that IAW VASRD §4.55 a muscle injury rating cannot be combined with a peripheral nerve rating of the same body part (unless they affect different functions.)  Thus, although the residual disability due to the compartment syndrome of the LE may be rated either IAW §4.73 (muscle injury) or IAW §4.124a (neurological conditions), only one rating is applicable in this case.  The Board first considered coding as 5399-5312.  The rating criteria are subjective with 0% for “slight,” 10% for “moderate,” 20% for “moderately severe,” and 30% for “severe” muscle injury.  The Board agreed that the CI’s symptoms were more than “slight,” described as “no cardinal signs or symptoms of muscle disability,” which are specified as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement.  The Board next reviewed the descriptions of “moderate” versus “moderately severe” muscle injury, which are very similar; both require the presence of one or more “cardinal signs or symptoms of muscle disability.”  However, the Board noted that the “moderately severe” rating includes evidence of a greater degree of muscle injury and objective evidence of defects or muscle loss, not present in this case - no evidence of muscle atrophy or persistent weakness was noted.  Therefore, the Board opined that the CI’s muscle injury was more closely analogous to “moderate” muscle injury, than “moderately severe,” and best rated 10%, coded as 5399-5310.

The Board next considered alternatively coding the residual disability due to the right CS as a nerve condition.  The Board considered that both the pre-operative and post-operative EMG/NCV studies showed bilateral LE injury to the deep peroneal nerve (also referred to as anterior tibial nerve) and at the C&P exam the CI reported paresthesia and decreased sensation in the distribution of the superficial peroneal nerve, noted to be scarred bilaterally at surgery.  Therefore, the Board considered the best nerve code for rating the residual disability in this case is 8521 (common peroneal nerve), which branches into the superficial and deep peroneal nerves in the leg and noted the rating criteria are subjective with 10% for “mild,” 20% for “moderate” and 30% for “severe” incomplete paralysis of the common peroneal nerve.  The orthopedic notes in the STR following the surgery documented normal nerve function including intact sensation of the RLE, but the CI had reported pain, tightness, and numbness of the RLE after surgery.  At the MEB exam the CI did not report abnormal sensation of the RLE and none was noted, but the C&P examiner documented decreased sensation in the superficial peroneal distribution.  Although the C&P examiner noted difficulty toe walking due to “LE weakness,” strength of the right leg was noted to be normal at both MEB and C&P exams, with normal reflexes and pulses noted at the C&P examination.  Member consensus was that the pain and sensory disturbances of the RLE and reported occasional weakness with weight bearing activities, but with normal strength and reflexes on exam was best described as “mild” incomplete paralysis, and rated 10%.  Thus, the Board found that either rating approach resulted in a 10% rating for the right CS and no higher.  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 adjudication for the right CS condition.

Left CS Condition. The post-operative course of the left LE (LLE) following the compartment release surgery was complicated by a wound infection.  The CI underwent a second surgery on 10 September 2008 for incision and drainage (I&D) of the wound and there was no sign of deep infection.  Following the I&D, the wound healed very slowly, thought to be due in part to continued motion of the scar with LE movements.  Notes indicated that the CI had his sutures removed and the wound re-opened.  At an orthopedic follow-up visit, the CI reported burning pain of the top of his foot.  Exam of the LLE was normal except for noted mild antalgic gait.  The CI was placed in a controlled ankle motion (CAM) boot to help his foot/ankle pain and reduce movement of the wound.  The examiner noted the CI was to continue to use pain medication and medication for nerve pain (Lyrica).  At the next follow-up visit on 16 December 2008, the CI reported medication was quite helpful and pain was better controlled.  He was noted to be wearing military boots without difficulty.  On exam normal gait and no abnormalities of the leg, foot, or ankle were noted.

At the MEB examination on 25 March 2009, 4 months prior to separation, the CI reported bilateral LE pain, left greater than right.  He also reported numbness and a feeling of “water running down his left leg” laterally.  The exam noted a mild limp and normal LLE strength.  There was a still healing 4 centimeter wound, without sign of infection.

At an orthopedic evaluation after the MEB exam on 23 April 2009, the CI reported increased left ankle pain without numbness and no new injury.  The wound was still not fully healed but complete exams of the leg and ankle were normal, with normal sensation in the peroneal nerve distribution and normal foot/ankle strength noted, but there was tenderness to palpation (TTP) of the anterior ankle ligaments and the CI had difficulty with heel and toe walking and hopping on one foot.  The examiner recommended use of the CAM walker again.  In April 2009 use of the CAM walker was stopped and the CI started therapy.  The final orthopedic note in record 13 July 2009 indicated the LLE wound was fully closed, the CI was in “no significant discomfort and was to wean off pain medication.

At the VA C&P examination on 2 September 2010, 13 months after separation, the CI reported symptoms of the bilateral LE pain, weakness, and sensory disturbances as noted above.  The exam was the same as for the RLE noted above, with the exception of a tender scar of the outside of the LLE.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left CS 10% coded as 5399-5312 (analogous to Group XII muscle injury) an analogous code for CS.  The VA rated the left CS 20%, coded 8599-8522 (analogous to severe incomplete paralysis of the superficial peroneal nerve).  The LLE course after surgery was complicated by infection and delayed wound healing.  During the wound healing phase the CI reported pain and sensory disturbances of the LLE and was given medications for nerve pain.  However, the CI reported the medication was very helpful and the last orthopedic follow-up in record (after the MEB exam) noted the wound was well healed and the CI had “no significant discomfort.”  The Board notes that all rating rationale applied to the right leg above applies to the left leg as well.  By the same rating rationale as elaborated for the right CS, the Board concluded that the residual disability of the left CS also achieved a 10% rating coded as either 5399-5312 or 8599-8522 and no higher.  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 adjudication for the left CS condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral knee pain, quadriceps tendonitis, chronic LBP and cervical pain conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board notes that the MEB forwarded two conditions of the knees-bilateral knee pain and quadriceps tendonitis-and the PEB adjudicated both conditions as not unfitting.  However, the noted knee pain was likely related to the tendonitis and therefore, both conditions are discussed together below.

Bilateral Knee Pain and Quadriceps Tendonitis Conditions.  The NARSUM noted the CI reported bilateral knee pain and stiffness since he jumped off a truck in April 2008.  He reported the left knee gave way sometimes and rated the pain in the knees 2/10, aggravated by walking, standing, and sitting.  The NARSUM noted that the CI reported no active treatment for the knee symptoms.  There were no notes regarding symptoms or treatment of either or both knees in record.  The MEB exam noted TTP of the quadriceps tendons and the knees were stable, without swelling or joint line tenderness.  Bilateral knee range-of-motion (ROM) was extension-flexion of 0-120 degrees (normal 0-140).  Serial orthopedic evaluations, primarily for the bilateral CS, noted that the CI was able to do five deep knee bends without problems 5 September 2008 and multiple evaluations of the bilateral LE noted a normal gait and no abnormality of either knee was documented.  Bilateral knee X-rays were normal.

Chronic LBP. The NARSUM noted the CI reported LBP that radiated to the left buttock area, but not below, rated 1-2/10, aggravated by prolonged standing or bending.  The CI reported no active treatment for the back symptoms.  The MEB exam noted no TTP and no muscle spasm.  There was a very remote treatment note in 1990 for neck and back pain after a fall, but no other notes for LBP were found in record.  Back ROM was flexion of 85 degrees (normal 90) and combined ROM of 225 degrees (normal 240).  Seated straight leg raise (SLR) was negative bilaterally.  there was some calf pain on the left noted with supine SLR, as noted above the calf wound was still healing.  Lumbar spine X-rays were normal.  As noted above EMG/NCV was performed and there was no evidence of a lumbar radiculopathy.

Cervical Pain. The NARSUM noted the CI reported localized neck pain, primarily stiffness on the right side of his neck.  The CI described the pain as intermittent and when present rated 5/10. The CI reported no active treatment for the neck symptoms.  As noted above a single remote note for neck pain after a fall was found in record.  The MEB exam noted TTP of the right side of the neck without muscle spasm.  Neck ROM was flexion of 40 degrees (normal 45) and combined ROM of 285 degrees (normal 340).

The bilateral knee pain, quadriceps tendonitis, chronic LBP and cervical pain conditions were not profiled and were not judged to fail retention standards.  The commander’s statement noted only that the CI’s duty performance was impaired by his physical profile limitations due to the bilateral CS.  All were reviewed 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:  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 matters of the left and right CS conditions and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudications.  In the matter of the contended bilateral knee pain, quadriceps tendonitis, chronic LBP and cervical pain 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.

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 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

DEPARTMENT OFTHE ARMY
ARMY REVIEW BOARDS AGENCY
251 18TH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

SAMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

06 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXX, AR20160003283 (PD201402793)

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