RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03898
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20030301

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Seaman Recruit, medically separated for “right proximal femoral shaft stress fracture” and “left proximal medial tibial shaft stress fracture,” 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 - 20030114	VARD - 20030411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Proximal Femoral Shaft Stress Fracture	5003-5255	10%	Right Femoral Stress Fracture	5299-5255	10%	20030122	
Left Proximal Medial Tibial Shaft Stress Fracture	5003-5262	10%	Left Tibial Stress Fracture	5262	10%	20030122	
Status-Post Laparoscopic Cholecystectomy	Cat III	Cholecystectomy	7318	10%	20030122	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Right Femoral and Left Tibial Stress Fractures.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed bilateral leg pain associated with the rigors of basic training, 2 months after entry and 9 months before separation.  She was diagnosed (X-ray, bone scan) with the stress fractures as described in the above rating chart, and was placed in convalescent status.  Follow-up imaging confirmed that the fractures were healing, but efforts at rehabilitation were unsuccessful in permitting the CI to complete her training.  Surgery was not indicated and she was referred for an MEB which in turn forwarded “right proximal femoral shaft stress fracture” and “left proximal medial tibial shaft stress fracture” to the PEB.  The outpatient STR evidence probative to functional impairment, range of motion (ROM), and other VASRD rating criteria was consistent with that from the NARSUM and VA examinations which follow.

The undated MEB NARSUM examination documented “8/10 pain in the right femur with prolonged ambulation” and “occasional left knee pain.”  There was no MEB NARSUM or STR indication of gait disturbance.  The physical examination recorded “moderate” tenderness of the right thigh and “mild” tenderness of the left tibia, and commented that ROM was “equal bilaterally.”  The commander’s non-medical assessment documented that the CI was “unable to participate in most physical activities” with no indication that she was impaired in routine activities.

A VA orthopedic Compensation and Pension (C&P) examination in January 2003,6 weeks before separation, documented “significant pain in the ... left tibia and right femur” increased by cold weather; and, did not elaborate specific functional impairment.  The examiner noted an improving course and good prognosis.  The physical examination recorded “walks slowly but without a limp,” “significant tenderness and mild swelling” over the left tibia, and diffuse tenderness of the right thigh.  Measured bilateral ROM of the hips and knees was normal, or modestly limited, in all planes (no minimum compensable limitations); and, bilateral knee examinations were negative for effusion, instability to stress testing, or signs of impingement (locking).

The Board directed attention to its rating recommendations based on the above evidence.  Both the PEB and VA rated the right femoral stress fracture at 10%, analogously coded 5255 (femur, impairment); and, the left tibial stress fracture at 10%, coded 5262 (tibia and fibula, impairment).  The Board agreed both of these codes specify complications of fractures (malunion, non-union) which were not present, but are commonly used analogously for uncomplicated fractures.  Both codes provide for rating of contiguous joint disability, and both offer the same scale:  10% for “slight” disability, 20% for “moderate,” and 30% for “severe.”  Both the PEB and the VA (based on the C&P evidence) arrived at the same 10% determination for each condition, the VA rating decision specifying that moderate disability was not supported.  There was no evidence for compensable ROM limitation, ratable joint findings or other criteria that would support a rating higher than 10% for either condition under any alternative code.  Members considered whether a 20% rating for moderate disability under 5255 or 5262 could be justified for either leg; but, agreed that the disability in evidence (logically confined to prolonged ambulation or strenuous activity), especially considering the improving course and anticipated outcome for stress fractures, was better aligned with the 10% than the 20% criterion.  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 right femoral or left tibial stress fracture conditions.

Contended PEB Condition:  Status-Post Laparoscopic Cholecystectomy.  While in rehabilitation status for her stress fractures, the CI developed biliary colic (gallbladder pain) and in November 2002, 4 months before separation, she underwent a laparoscopic cholecystectomy.  The MEB NARSUM, corroborated by STR notes, documented an uncomplicated course; and, did not indicate that there were any significant symptoms at separation.  A VA C&P examination, 6 weeks before separation and contemporary with the orthopedic examination, documented “still has occasional needle-like pain in the upper abdomen” without need for medication.

The Board’s main charge was to assess the fairness of the PEB’s determination that the condition was not unfitting.  Members agreed that there was no performance-based evidence indicating that the condition interfered with duty requirements to an extent that would have prohibited further military service.  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 post-cholecystectomy condition; thus, it was not eligible for service rating.

BOARD FINDINGS:  In the matter of the right femoral and left tibial stress fracture conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  In the matter of the contended status-post laparoscopic cholecystectomy condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20140604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
          (b) CORB ltr dtd 21 Sep 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN