RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03140
BRANCH OF SERVICE:  MARINE CORPS	SEPARATION DATE:  20040915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Motor Vehicle Operator) medically separated for left tibial stress fracture, rated at 10%.  

CI CONTENTION:  The applicant requests consideration of all conditions in his application.  His 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 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 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 20040617	VA* - (~2 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Tibial Stress Fracture...	5022-5003	10%	Status Post Left Tibial Nonunion Stress Fracture	5262	10%	20040709	
Left Patellofemoral Pain Syndrome	Cat II	Left Knee Patellofemoral Syndrome with Iliotibial Syndrome	5099-5019	10%	20040709	
Conditions x 0 (Not In Scope)	Other x 10	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20041104 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Left Tibial Stress Fracture Condition.  The earliest report in the service treatment record (ST) dated 15 June 2001 indicated the CI, who reported a year-long history of shin pain, had a healing stress fracture of the distal shaft of the left tibia.  In December 2001, the CI was evaluated for pain in the left lower extremity for 3 weeks when running and another radiology report indicated the CI had a recurrence of the pain pattern with a subacute stress injury to the distal shaft of the left tibia with a localized cortical (dense and contact part of the bone) thickening with a periosteal (layer around the bone) response and no abnormality of the fibula.  In May 2002 the CI noted no change in symptoms despite limited duty and nonsteroidal anti-inflammatory drugs (NSAIDs).  He also noted a “lump” under the skin.  An X-ray series demonstrated a healing stress fracture of the distal left tibia and negative findings for the right tibia and the fibula bilaterally.  By November 2002, X-rays were consistent with a non-union, status post stress fracture of the midshaft of the left tibia.  Treatment consisted of touch-down weight bearing with crutches, although the CI was non-weight bearing since 13 November 2002.  A CAM walker (an adjustable, boot-like orthopedic device) was added to the treatment protocol in December 2002.  Increased healing was noted on X-rays in January 2003.   Progressive weight bearing to 50 pounds continued through June 2003 and by July 2003 the CI was nearly full weight bearing.  By early September 2003, the CI was off crutches without pain, had weaned out of the CAM walker by the end of September, and was doing some walking on a treadmill.  In December 2003 the CI was able to run between 1 and 1.5 miles without pain.  X-rays of the tibia showed abundant callus (thickening) with a widened cortical defect (non-union) for which a bone stimulator was introduced.  In January 2004 the CI had a continued lucency (non-union) on X-ray.  The CI reported pain of the left tibia and left knee (see below) and popping of both knees with an unremarkable examination except for a 1cm tender deformity of the left anterior tibia.  The CI was given a surgical option to repair the tibial non-union by placement of an intramedullary nail, but he requested a second opinion.  X-rays of the left tibia/fibula in July 2004 revealed a benign periosteal reaction and a lucent defect in the anterior cortex of the mid left tibia.  

The MEB narrative summary (NARSUM) dated 22 April 2004 noted there were two previous MEB reports in April and December 2003 for the diagnosis of a left tibial stress fracture.  Apparently the CI did not use the bone stimulator and by 16 April 2004 the CI reported his ability to run continued to decline due to the pain in his tibia.  Physical examination on 16 April 2004 was directed toward the knee (see below).  X-rays revealed the fracture to be unhealed with a complete black line through the anterior cortex.  The NARSUM author opined the CI would not be able to perform active duty requirements and noted the CI was apprehensive and did not want to have surgery.  The CI had at least two periods of limited duty with limitations of no running, no humping, no marching, no prolonged standing or waling greater than 15 minutes, no physical fitness training and no deployment.  The Non-Medical Assessment (NMA) dated 4 May 2004 indicated that due to the severe stress fracture of his left tibia, the CI was unable to operate all government vehicles and noted that despite therapy for 2 years no progress had been made; and, the CI’s injuries prohibited his military duties.  

At the MEB examination dated 4 May 2004, the CI reported on DD Form 2807-1, Report of Medical History, that he had pain in the knees and the severe stress fracture was still open.   The MEB physical examiner noted on DD Form 2808, Report of Medical Examination, dated 3 May 2004 an approximately 1 cm bony tender deformity of the left anterior tibia 15 cm superior to the talus (a bone at the junction of the ankle and foot) with a lateral malleolus (outer side of the ankle) positive tuning fork test (to determine the presence of a fracture) and an antalgic gait. 

At the VA Compensation and Pension (C&P) examination dated 9 July 2004, performed 2 months before separation, the CI reported pain in the shins since April of 2001, which was subsequently diagnosed as a stress fracture of the mid-shaft of the left tibia.  Despite 2 years of conservative therapy, he had some improvement, but continued to have tenderness in his tibia and developed symptoms of the patellofemoral pain syndrome (see below).  X-rays demonstrated a widened cortical defect in the left tibia and the CI continued to have symptoms of pain especially after exertion.  He was able to work, but he was unable to do the physical training requirements.  On examination the general appearance of the left tibia and fibula was normal and there was tenderness on palpation of the left tibia where there was mild callus formation in the mid-tibia at the point of the stress fracture.
Left Patellofemoral Pain Syndrome Condition.   In January 2004 the CI reported pain of the left tibia and left knee and popping of both knees with an unremarkable examination.  By February 2004, the CI reported worsening of the left knee with buckling, but without swelling or locking.  There was crepitus at the patellofemoral joint, a patellofemoral compression test was positive, and the lateral patellar facet was tender, but there was no effusion or laxity.  The CI had steroid injections to treat the patellofemoral pain syndrome (PFPS).  X-rays of the left knee were normal.

The MEB narrative summary (NARSUM) dated 18 April 2004 noted the CI reported clinical regression after initial improvement of the left tibia with decreased ability to run and pain and popping in his left knee associated with use of the stairs.  The left knee examination was consistent with the patellofemoral pain syndrome (PFPS) and was not much better after a second steroid injection.  Examination revealed no knee effusion; ligaments were stable; and there was tenderness at the patellofemoral joint with positive patellofemoral compression.  At the MEB exam, the CI reported knee trouble on DD Form 2807-1 dated 4 May 2004.  The MEB physical examination dated 3 May 2004 noted bilateral knee crepitus.  Neither the NMA nor the LIMDU explicitly addressed the left knee condition, although the NMA noted the CI’s injuries prohibited his military duties.
 
At the VA Compensation and Pension (C&P) examination dated 9 July 2004, performed 2 months before separation, the CI reported he continued to have pain and stiffness in his left knee and locking pain and crepitus without a history of joint effusion or recurrent subluxation.  The examiner noted the CI was diagnosed with iliotibial band syndrome and patellofemoral pain syndrome in his left knee and was treated with a steroid injection in his left knee with considerable improvement. The CI continued to do stretching exercises, but had some functional impairment in his left knee since he was not able to do prolonged standing.  On examination the general appearance of the knee joints was normal.  The CI had tenderness on palpation of the lateral aspect of the left knee joint adjacent to the patella and the ROM of the left knee was limited to 0 to 90 degrees of flexion with pain at the end of the ROM; extension was normal, but he had crepitus on extension.  There was no laxity.  He described weakness, fatigue and lack of endurance, but the major functional impact was due to pain with prolonged standing or exertion.  

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Knee ROM
(Degrees)	PT ~8 Mo. Pre-Sep
	MEB ~3 Mo. Pre-Sep
	VA C&P ~2 Mo. Pre-Sep
	
Flexion (140 Normal)	FROM
	
“full range of motion from 0-135”
	0-90	
Extension (0 Normal)			0	
Comment	Mild crepitance	Without effusion; patellofemoral crepitation; and positive patellofemoral compression test	Pain at the end of flexion; crepitus on extension	
§4.71a Rating	0%	10% possible	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5022-5003 (Periostitis-Degenerative arthritis) for the Category I left tibial stress fracture unresponsive to nonoperative measures and the left patellofemoral pain syndrome was determined to be a related Category II condition.  The VA assigned a 10% rating using code 5262 (Tibia and fibula impairment) for status post left tibial nonunion stress fracture and a 10% rating using code 5099-5019 (Bursitis) for left knee patellofemoral syndrome with iliotibial syndrome.  The Board sought a route to a higher rating.  The tibia stress fracture can also be rated using code 5262 (Malunion), which also encompasses the knee condition (PFPS).  The Board, aware that a Category II condition contributes to a Category I condition, determined that the Category II knee condition did not contribute to the Category I tibial stress fracture although it was a related to it.  Instead the Category II knee condition seemingly occurred as a result of the Category I tibial stress fracture, thereby raising the question whether it was separately unfitting.  Clearly, with a decreased ROM, crepitus, and a positive patellofemoral compression test, the combination offers a preponderance of evidence and favors an unfitting diagnosis.  However, the knee examination with a decreased ROM of 90 degrees cannot be separately ratable, but it did warrant a Board discussion about a separate rating using either analogous code 5099-5003 or 5099-5019 at 10% versus the distinction of marked, moderate, or slight knee disability under code 5262 noted above.  Evidence did not support a marked knee disability; however, the Board discussed the clinical findings and functional limitation of a moderate knee disability at 20% versus a slight knee disability at 10%.   The Board also sought an additional route to higher rating and noted there was nonunion of the tibia, but loose motion requiring a brace was not in evidence; therefore, a 40% rating is not applicable.  An additional rating in the absence of ankylosis, subluxation, or meniscal involvement is likewise not applicable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left tibial stress fracture and patellofemoral pain syndrome condition. 

BOARD FINDINGS:  In the matter of the left tibia stress fracture and patellofemoral pain syndrome conditions, the Board unanimously recommends a disability rating of 20%, coded 5262 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Tibial Stress Fracture/Left Patellofemoral Pain Syndrome 	5262	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 21 Jan 16 ICO XXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 07 Jan 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 11 Jan 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 19 Jan 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (k) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

					XXXXXXXXXXXXXXX
					Assistant General Counsel
					(Manpower & Reserve Affairs)