RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04240
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, M1 Armor Crewman, medically separated for “bilateral exercise induced compartment syndrome,” with a disability rating of 20%.

CI CONTENTION:  Condition continues to worsen.  He was not evaluated for PTSD or TBI.  He was given a higher rating for his conditions by the VA.  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 - 20090316	VARD - 20090622	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Exercise Induced Compartment Syndrome…	8799-8723	20%	Compartment Syndrome, Right Lower Extremity…with
Postoperative Tender Scarring	8723-7804	10%	20090610	
			Compartment Syndrome, Left Lower Extremity, with
Postoperative Tender Scarring	8723-7804	10%	20090610	
Asthma Mild Intermittent Exercise Induced	Not Unfitting	Asthma	6602	10%	20090610	
Lumbosacral Spondylolisthesis…	Not Unfitting	Lumbosacral Spondylolisthesis, Joint Space Narrowing, and Pars
Defect, L5, S1	5239	40%	20090610	
Hypertension Controlled	Not Unfitting	Hypertension	7101	0%	20090610	
Irritable Bowel Syndrome	Not Unfitting	Gastroesophageal Reflux Disease with Irritable Bowel Syndrome	7319-7346	10%	20090610	
GERD	Not Unfitting					
Obstructive Sleep Apnea	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20090610	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	
ANALYSIS SUMMARY:

Bilateral Exercise Induced Compartment Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral exercise induced compartment syndrome condition existed for several years and was exacerbated after prolonged walking or running.  Concern for compartment syndrome was first raised in September 2007.  X-rays demonstrated no bony or soft tissue abnormalities.  By the end of September, the CI had defects in fascia (connective tissue surrounding muscle) through which muscle herniated causing pain; this was noted in a follow-up examination to have occurred after the CI ran or used a treadmill.  The CI underwent a fasciotomy (surgical opening of the connective tissue layer) of the left lower leg on 28 January 2008 and had follow-up postoperative physical therapy.  Three months post-surgery the CI was healing well and had a normal gait.  On 25 August 2008, the CI reported similar symptoms of lateral pain and numbness in the right leg, which occurred after running 10-15 minutes.  On 23 September 2008, the CI underwent a right lower extremity anterior and lateral compartment release.  Six weeks postoperatively the right leg operative site was well healed with mild tenderness to pressure.  The range of motion (ROM) of the right lower extremity was within normal limits and the CI’s gait was normal.  In November 2008, the CI reported bilateral anterior ankle/calf pain with walking, but did not use an assistive device or brace.  A medical examination in November 2009 noted bilateral lower extremity scars status post surgery, which were intact and without obvious swelling or tenderness.  X-rays of the right and left knees obtained for bilateral knee pain revealed no bony or soft tissue abnormalities in February 2009.

The MEB narrative summary (NARSUM) dated 29 December 2008, 4 months before separation, indicated the bilateral anterolateral compartment fasciotomies lessened the CI’s symptoms to some degree, but they continued to restrict his ability to perform his Military Occupational Specialty (MOS).  He had bilateral anterior ankle and calf pain with walking and could only walk about two blocks at a brisk pace before he had to stop.  He also had tingling diffusely in the feet and reported easy fatigability.  On examination he walked with a normal heel/toe reciprocal gait and had well-healed incisions over his bilateral anterolateral calves.  He had Tinel’s signs (to determine nerve irritation) bilaterally over the distal portion of the incision which radiated into the dorsal aspect of his foot; the compartments were soft.  Additionally, and he had a full ROM in his knees and ankles and was neurovascularly intact with 5/5 muscle strength bilaterally.  His MOS required him to get on and off tanks and to run and do road marches, but because of functional limitations and pain associated with his condition he was unable to do so.  The commander’s statement dated 6 January 2009 indicated the CI could not perform his assigned MOS duties.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 January 2009, 4 months prior to separation, the CI reported surgery on both legs. The examiner noted lower extremity surgical scars and no obvious swelling or tenderness.  

At the VA Compensation and Pension (C&P) examination in June 2009, performed 1 month after separation, the CI reported numbness in the feet and anterior shin areas since around 2006 or 2007.  Pain with sensations of pins and needles occurred in the heels and great toes about 2-3 times a week along with calf muscle pain bilaterally 1-2 times a week and tenderness of the surgical scarring.  The diagnosis was bilateral calf exertional compartment syndrome with Group XI and Group XII muscles involved and sensory peripheral neuropathy in areas of scarring bilaterally without weakness involving the peroneal cutaneous nerves bilaterally.  Superficial scars were 7.5cm x 5mm on the left anterolateral leg and 6.5cm x 3mm on the right anterolateral leg.  Sensation was decreased over the scars bilaterally; muscle strength and function were normal with no tissue loss.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating analogously coded 8799-8723 code (neuralgia-anterior tibial nerve (deep peroneal)), citing an atraumatic onset of bilateral anterolateral lower leg pain.  The VA assigned a 10% rating analogously coded 8723-7804 based on the VA C&P examination 1 month prior to separation, for the right leg (neuralgia-anterior tibial nerve to scar(s), unstable or painful).  The VA also assigned a 10% rating analogously coded 8723-7804 for the left leg.  The Board noted the PEB assigned a single rating for the bilateral exercise induced compartment syndrome.

The PEB combined the bilateral exercise induced compartment syndrome conditions as a single unfitting condition coded 8799-8723, presumably for a severe disability that included contributions from each leg, rated 20%.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and that there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining whether the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the Disability Evaluation System or be found unfit because of a physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral exercise induced compartment syndrome conditions was presented together above.  In this case, the bilateral condition was explicitly mentioned in the profile, and the bilateral exercise induced compartment syndrome condition was implicated by the NARSUM, but was not as explicit in the commander’s statement.  Members agreed that each extremity condition is reasonably justified as separately unfitting and that identical coding and ratings are applicable.

Board members agreed that each leg had improved post-operatively and neither condition rose to a severity level higher than moderate, which warrants a 10% rating for each lower extremity.  Board members also considered ratings using muscle codes 5311 (Group XI) and 5312 (Group XII).  Again members discussed whether each extremity independently would first qualify for the use of a muscle code; second whether the condition rose to a level of severity greater than moderate; and third whether a combined rating of each extremity would fall below or exceed the PEB assigned rating of 20% for the bilateral condition.  While the cardinal signs and symptoms of muscle disability include loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement, the CI did have fatigue with prolonged walking, but did not meet the criteria for a muscle code application greater than a moderate disability.  Whether each condition was mild was also considered thereby affording a 0% rating for each extremity; however, as noted above, the Board cannot recommend a rating that produces a lower combined rating than that of the PEB.  Therefore a 10% rating for each extremity was considered reasonable, but provides no additional benefit to the CI; however application specific to each extremity provides clarity and specificity.  After due deliberation, consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right lower extremity exercise induced compartment syndrome condition, coded 8723, and a disability rating of 10% for the left lower extremity exercise induced compartment syndrome condition, coded 8723.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that asthma, low back pain, hypertension, irritable bowel syndrome (IBS) and gastroesophageal reflux disorder (GERD) and obstructive sleep apnea (OSA) were not unfitting.  The asthma, low back pain, hypertension, IBS and GERD conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.

Asthma.  The MEB NARSUM Addendum dated 4 March 2009 indicated the CI had mild intermittent exercise induced asthma, which began with symptoms of breathlessness precipitated by cold air in the prior year.  Treatment consisted of an Albuterol ( bronchodilator) inhaler prior to any exertion, exercise or prolonged walking.  Other medication including Advair (inhalational steroid/bronchodilator combination) and Singulair (oral indirect-acting bronchodilator) were discontinued.  The CI was a smoker, but quit some 60 days prior to the examination.  The examiner noted the CI’s symptoms were manageable and did not interfere with his duty performance.  At the VA examination, the CI was noted to have mild obstructive and restrictive defects with an FEV-1 (forced expiratory volume in one second) post-bronchodilator of 83.5% predicted and a FEV-1/FVC (forced vital capacity) of 79%.

Low Back Pain. The MEB NARSUM addendum documented that during the prior year, the CI had prolonged episodes of intermittent low back pain.  X-ray findings showed a bilateral pars defect at L5 with significant spondylolisthesis manifested by anterior slippage of L5 on S1 and a spina bifida occulta (a small gap in one or more bones of the spine).  Physical therapy improved his condition significantly and he had only minimal back pain with heavy lifting.  The CI moderated his activities to remain essentially pain free and took Mobic (nonsteroidal anti-inflammatory drug) when he had a mild flare-up.  At the VA examination, tenderness of the paravertebral musculature without muscle spasm was noted.  The ROM measurements were forward flexion to 40 degrees and extension to 15 degrees.

Hypertension.  The MEB NARSUM indicated the CI had hypertension, was asymptomatic, and was well controlled with lisinopril (an antihypertensive medication); however, blood pressure readings were 135/86 on 12 January 2009 at the MEB physical examination, 152/83 on 13 February 2009, 143/67 on 27 February 2009 and 151/76 on 5 March 2009 when amlodipine (antihypertensive medication), was on his medication list.  Blood pressure readings at the VA examination showed diastolic pressures in the 90’s and systolic pressures in the 140’s.

IBS.  The CI reported a long history of intermittent cramping and loose and watery stools, occasionally up to 7-8 times per day.  The symptoms were exacerbated by eating and activity; however, the CI did not report rectal bleeding, and reportedly he took no medications, although loperamide (to treat diarrhea) was listed as a prescribed medication.

GERD.  The CI reported intermittent symptoms of chronic coughing and of heartburn that were significantly exacerbated when he was prescribed Advair for his mild asthma; treatment was with omeprazole, a proton pump inhibitor medication.  Since discontinuing the medication he had rare GERD symptoms for which he occasionally took an over-the-counter antacid.

The aforementioned 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 at separation.  After due deliberation, and 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 asthma, low back pain, hypertension, IBS and GERD conditions; and so, no additional disability ratings are recommended.

OSA.  The CI noted a 1 to 2-year history of daytime somnolence and snoring noted by his wife.  A sleep study was abnormal in July 2008 and he was treated with continuous positive airway pressure (CPAP) and advised to undergo weight loss counseling.  At a follow-up visit his blood pressure was 160/101 and his weight was 265 pounds.  According to the MEB NARSUM addendum, his episodes and symptoms, including daytime somnolence and sleep patterns, improved with CPAP machine use; however, a note in the STR dated 23 February 2009 (at which time his blood pressure was 155/94 and his weight was 275 pounds), indicated the CI had not used the device because he felt more tired when he used it than when he did not; and he had trouble using the CPAP because he slept on his stomach after knee surgery.

The OSA was explicitly implicated in the commander’s statement and was profiled as P2 with the requirement the he must use the CPAP machine at night; however, the condition was judged to meet retention standards by the MEB.  The aforementioned was reviewed and considered by the Board.  There was performance-based evidence from the record that the OSA condition significantly interfered with satisfactory duty performance at separation as the commander noted:  the CI could not perform his assigned MOS duties in the unit; the CI cannot perform his duties without unreasonable number and duration of rest periods; and due to the CI’s need to use a sleep machine, he is unable to do night operations where sleep is degraded.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the OSA condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 6847 and meets the VASRD §4.97 criteria for a 50% rating.

BOARD FINDINGS:  In the matter of the bilateral exercise induced compartment syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 8799-8723 for the right lower extremity and a disability rating of 10%, coded 8799-8723 for the left lower extremity both IAW VASRD §4.124a.  In the matter of the contended asthma, low back pain, hypertension, IBS and GERD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended OSA condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 50%, coded 6847 IAW VASRD §4.97.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Lower Extremity Exercise Induced Compartment Syndrome	8799-8723	10%	
Left  Lower Extremity Exercise Induced Compartment Syndrome	8799-8723	10%	
Obstructive Sleep Apnea	6847	50%	
RATING (w/ BLF)	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140826, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160011487,  XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 60% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure