RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03645
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090617

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “bilateral medial tibial plateau stress fractures,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  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 based upon a 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 – 20090604	VARD - 20101002	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Medial Tibial Plateau Stress Fractures	5299-5262	20%*	Bilateral Knee Tendonitis	5260	0%	STR	
			Bilateral Knee Tibial Plateau Fractures	5262	0%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Medial Tibial Plateau Stress Fractures.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an onset of bilateral leg pain (“just distal to the knees”) in the middle of basic training.  The CI was diagnosed with bilateral medial tibial plateau stress fractures by bone scan.  There was a paucity of STR entries in the file, and those that were present were consistent with the evidence from the NARSUM.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow resumption of training; and, the CI was referred for MEB which in turn forwarded “chronic bilateral pain just distal to each knee with history of medial tibial plateau stress fracture” to the PEB.  
The NARSUM examination on 7 May 2009 (5 weeks before separation) documented “constant bilateral knee/leg pain” rated 7/10 with exacerbations to 9/10 “with all weight bearing activities.”  The physical examination recorded a normal gait, tenderness over the tibial plateaus; and, the absence of effusion, stability to stress testing in all planes, and negative signs of impingement (locking) for both knees.  Measured ROM (goniometry by physical therapy) was flexion to 130 degrees right and 135 degrees left (normal 140, 45 for minimum 10%) and bilateral extension of 0 degrees (normal), specifying “no pain” for all measurements.  The CI failed to report for a scheduled VA joint examination, and there was no temporally probative post-separation evidence for these conditions.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s separate 10% ratings were coded analogous to 5262 (tibia and fibula, impairment of) which provides for rating of contiguous knee or ankle joint disability.  The PEB’s 10% ratings were consistent with “slight” knee disability; and, 5262 offers ratings of 20% for “moderate” and 30% for “marked” disability.  The VA (based on the same service evidence) pursued an atypical rating scheme, with separate bilateral ratings of 0% under codes 5360 (limitation of knee flexion) and 5262.  It was noted that neither of these codes offer bilateral rating; so, in order to comply with §4.71a, separate 0% ratings would have to have been conferred if it were judged that a minimum compensable rating could not be supported for either leg under either code.  Members agreed that the PEB’s coding approach was an optimal choice for rating in this case.  Although code 5262 specifies complications of fractures which were not in evidence, the analogous application was justified.  Members further agreed that the evidence did not support separate functional impairment that would justify a higher rating higher than 10% under criteria of 5262.  There was no evidence for compensable ROM impairment, frequent effusions, or locking which would support a rating higher than 10% under any applicable code; and, no grounds for additional rating of instability.  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 of the bilateral tibial plateau stress fractures.

BOARD FINDINGS:  In the matter of the bilateral tibial plateau stress fractures 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.  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 20140729, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017049 (PD201403645)

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