RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-03107
BRANCH OF SERVICE:  Army                                                                    SEPARATION DATE: 20081212

Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Intelligence Analyst, medically separated for “bilateral leg pain” with a disability rating of 20%.

CI CONTENTION:  The CI made no specific contention in the application.  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 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:  

SERVICE PEB – 20080630	VARD - 20090417	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Exertional Compartment Syndrome	5399-5312	20%	Compartment Syndrome, Left Leg 	8523	10%	20080902	
			Compartment Syndrome, Right Leg	8523	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Exertional Compartment Syndrome.  The service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 12 October 2007 indicated the CI had a history of lumps of both of the lower legs after physical training associated with pain.  Conservative therapy including short term profiles and pressure stockings did not provide relief for herniations of the anterior tibial muscles bilaterally through fascial (membrane surrounding muscle) defects confirmed by ultrasound studies.  
Because of persistence of symptoms the CI underwent bilateral mesh repairs of the herniations in June 2004.  In July 2004 the right operative area became infected and a second surgery was performed, which healed by secondary intention with packing and dressing changes.  Pain persisted when running and the CI was felt to have an exertional compartment syndrome.  Compartment pressure readings after exercise were 41 mm on the right and 61 mm on the left, both of which were abnormally elevated.  In April 2005, the CI underwent bilateral fasciotomies to open up the anterior compartments and relieve the pressure buildup.  However, pain persisted and he took tramadol, (an opioid-like medication) for pain relief.  When deployed, he sat for extended periods and did hard manual work that other members of his unit were incapable of doing.  Despite of leg swelling and pain he was able to perform his duties well; however, he was evacuated for issues related to hypothyroidism.  He would get numbness and tingling on top of the feet with standing for 20-45 minutes, more so on the right.  The NARSUM examiner noted a scar of the left leg 10 cm vertical by 10 mm wide with slight tenderness.  A “puffed out area” of the left leg measured 6 cm vertical by 3 cm wide was medial to the upper area of the scar and was soft to palpation.  Three surgical scars were present on the right leg, the largest was  9.5 cm by 3.2 cm wide with a puffed out area medially that was 10 cm by 3 cm, which was not tender to palpation.  A vertical scar was 3.2 cm by 5 mm and the other scar was 3.0 cm by 4 mm.  There was no keloid formation.  Motor testing was 5/5 including dorsiflexion and inversion.  There was diminished sensation to pain in the area between the scars on the right.  The CI’s gait was slightly abnormal when he planted his right foot flat instead of laying it down and rolling it smoothly.  Neurologic examination was unremarkable except reflexes on the left knee and ankle were 2+ and on the right they were 1+.  The NARSUM diagnosis was bilateral exertional compartment syndrome involving the anterior tibialis muscle compartments with recurrent leg (tibial) strains.

At the MEB examination dated 12 October 2007 and updated on 8 May 2008, the CI reported bilateral compartment syndrome and nerve damage from the first leg surgery and a hematoma after the third leg surgery in 2005.  The examiner noted surgical scars on both lower legs.  A permanent L3 profile was issued on 21 May 2008 and for bilateral leg pain after fasciotomies with limitations of the 2-mile run and all military functional activities except wearing a protective mask and all chemical defense equipment.  Additional restrictions included no running, no rucking, no marching/road marching, and no jumping.  Lower body weight training was permitted as tolerated as well as an alternate aerobic event for the physical fitness testing.  An Addendum dated 3 June 2008 noted there was no medical contraindication for the CI to perform pushups or the swim event and the CI should be allowed the maximum amount of training up time to any testing.  The commander’s statement dated 16 June 2008 indicated the CI was not performing his duties due to bilateral leg fasciotomies.  

At the VA Compensation and Pension (C&P) examination dated 2 September 2009, performed 3 months before separation, the CI reported bilateral lower extremities herniation of the anterior compartment with mesh repairs and subsequent surgical debridement of an infection of the right lower extremity.  Continued pain with fast walking resulted in bilateral fasciotomies of the lower extremities with a progressively worse course since onset and treatment with tramadol.  On examination of the right leg there was decreased sensation and coolness 13 cm x 8 cm on the lateral lower leg with normal muscle strength.  On the left there was an areas of coolness to touch below the surgical site with normal muscle strength.  Pain in the anterior tibialis muscles bilaterally was present at the limits of the range of motion (ROM) of the ankles and there was increased pain with repetition.  The disability’s impact was decreased mobility, problems with lifting and carrying, lack of stamina, weakness or fatigue, and pain.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using 5399-5312 (Group XII:  Function: Dorsiflexion...moderate) for bilateral exertional compartment syndrome and further delineated and rated the left lower extremity compartment syndrome condition at 10% and the right lower extremity compartment syndrome condition at 10% and applied the bilateral factor (BLF) IAW VASRD §4.26 and the ratings were combined IAW VASRD §4.25.  The VA assigned a 10% rating using code 8523 (anterior tibial nerve, deep peroneal-incomplete paralysis moderate) for compartment syndrome, left leg, with recurring tibial strains and a 10 % rating using code 8523  for compartment syndrome, right leg, with recurring tibial strains.  The VA additionally assigned a 0% rating using code 7805 (scars, other) for surgical scars, right lateral lower leg and a 0% rating using code 7805 for surgical scar, left lateral lower leg.  Although the PEB combined the bilateral exertional compartment syndrome condition as a single unfitting condition and rated it 20%, left and right lower extremities were separated and independently rated at 10% each.  Therefore, it is not necessary for the Board to pursue separate fitness determinations and ratings by uncoupling the conditions.  While sensation was diminished on the right leg, there was no functional loss or limitation to warrant an additional rating assuming it would not involve pyramiding IAW VASRD §4.14, which is to be avoided.  The Board considered use of code 5262 (tibia and fibula impairment), but there was neither nonunion nor malunion with either knee or ankle disability.  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 bilateral exertional compartment syndrome condition.  

BOARD FINDINGS: In the matter of the bilateral exertional compartment syndrome condition and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication.  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 20140622, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160011108 (PD201403107)

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