RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00011
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1, Basic Trainee, medically separated for lower extremity pain, with a disability rating of 10%.

CI CONTENTION:  The applicant makes no specific contention 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 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 IPEB – Dated 20020712	VA - (Based on Service Treatment Records (STR))	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Extremity Pain, due to Tibial Stress Fractures	5099-5003	10%	Stress Fractures, Bilateral Medial Tibial Plateaus & Shafts	5299-5010	10%	STR	
COMBINED RATING:  10%	COMPLETE COMBINED VA RATING:  10%	

ANALYSIS SUMMARY:  

Chronic Lower Extremity Pain, due to Tibial Stress Fractures.  The Medical Evaluation Board (MEB) narrative summary (NARSUM) detailed that the CI complained of bilateral knee and shin pain in his third week of training, and that it had been “going on since the beginning of training.”  He stated that he had constant pain, no history of trauma, and that he “was not a very physical person in terms of running before coming into the service.”  A bone scan showed increased uptake over the bilateral medial tibial plateaus (left greater than right) and the bilateral tibial shafts.  He was diagnosed with bilateral stress fractures, and it was decided due to the CI’s age and the severity of his stress fractures, that he would not be able to complete training, so an MEB was initiated.

At a primary care appointment on 12 June 2002, the CI complained of “pain in legs” for a week.  At an orthopedic appointment on the same day, the CI complained of bilateral (left greater than right) lower extremity pain.  On examination, there was tenderness over the bilateral medial tibial plateaus, patellar tendons, and mid-tibial shafts.  A DD Form 2808, Report of Medical Examination, was completed on 20 June 2002 (5 weeks prior to separation), and the CI complained of “multiple stress fractures in knees and legs.”  There was tenderness to palpation from the ankle to knee (on bony surfaces) and the knee medial joint line.  The examiner’s diagnosis was bilateral lower extremity stress fractures.

The MEB NARSUM was completed one week later (27 June 2002) and showed tenderness to palpation over the bilateral medial tibial plateaus, patellar tendons, and mid-tibial shafts.  There was no effusion, joint line tenderness, varus or valgus instability; and Lachman’s sign was negative (indicating no instability of the anterior cruciate ligament).  A DA Form 3349, Physical Profile, was generated on 3 July 2002, and the diagnosis was “multiple stress fractures.”  The commander’s statement indicated the CI was physically incapable of reasonably performing his duties, but did not refer to the specific condition or whether it was unilateral or bilateral.

The VA Compensation and Pension (C&P) examination was accomplished on 5 November 2002 (4 months after separation), and the CI was working as a sales associate at Walmart.  He stated that his knees bothered him 24 hours a day, 7 days a week, with a steady pain that he rated as 7/10.  He also had a sharp, shooting pain that occurred 3 to 4 times a day in the medial and lateral femoral condyle area just proximal to the patellae, which lasted for 90 seconds each time, 3 to 4 times a day.  He was unable to kneel, squat, get out of a chair, or get up off the floor.  On examination, the CI was noted to have an antalgic gait and station, walking stiff-legged with his knees straight.  On examination, bilateral knee extension was 0 degrees (normal), flexion 120 degrees (normal 140), with pain on active and passive range of motion (ROM).  There was pain with palpation over the distal femoral condyles bilaterally, and crepitus with patellar motion in the left knee (only).  There was no ligamentous laxity or instability.  He had no muscle atrophy in the vastus medialis or quadriceps mechanism, but he did have deconditioned calf muscles. He could toe walk and heel walk.  The diagnosis was “Stress fractures of bilateral medial tibial plateaus and shafts, with residual pain.”  

At a VA orthopedic consult on 13 March 2003 (8 months after separation), the CI reported continued problems with bilateral knee pain; he also noted “some buckling and intermittent effusions” but no locking.  ROM of the left knee was painless and from 0 to 130 degrees with some crepitus at the end; right knee ROM was not reported.  Ligaments were intact, and there was a positive McMurray’s test (for meniscus damage/tears) on the left.  Magnetic resonance imaging later in the month showed a tear of the posterior horn of the medial meniscus of the right knee and possible radial tear of the posterior horn of the medial meniscus of the left knee.  The VA determined that the meniscal tears were not service connected and not related to the tibial stress fractures.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the two lower extremities together at 10%, analogously coded 5003 (Degenerative arthritis), citing slight/frequent pain.  The VA initially rated the two tibias together at 10%, analogously coded 5010 (Arthritis due to trauma), based on Service examinations.  A second VA rating decision (VARD) was accomplished on 24 January 2003, after the VA C&P examination on 5 November 2002, and rated the right and left tibias at 10% each, analogously coded 5022 (Periostitis), citing painful motion.  The Board noted that periostitis code reflected the actual unfitting condition (stress fractures) better than either of the other two codes (5003 or 5010).

The Board first considered if both lower extremities, having been de-coupled from the combined PEB adjudication, were reasonably justified as separately unfitting as described above.  The CI complained of bilateral lower extremity symptoms throughout the entire service treatment record (STR), although at times the symptoms were reported to be worse on the left.  The bone scan showed significant pathology of both tibias, although the uptake was worse on the left medial tibial plateau.  All examinations showed significant physical findings of both legs.  The NARSUM and the DD 3349 (profile) did not differentiate between the two extremities, and the commander’s memorandum did not address the condition specifically.  As there was very little documented clinical difference between the two extremities, members agreed that the functional limitations in evidence justified the conclusion that both conditions were integral to the CI’s inability to perform his specialty; and, accordingly separate ratings were recommended.

The VA C&P examination supported a rating of 10% based for both knees as there was pain with active and passive ROM.  The MEB NARSUM examination failed to document ROM or whether there was any painful motion.  However, the MEB NARSUM and the orthopedic examination (12 June 2002) both detailed constant pain, pain with ascending and descending stairs, and pain with ambulation; and the DD 3349 listed many activity limitations.  Although there was no directed evidence from the NARSUM or STR that painful motion was present, there was no directed evidence refuting its presence.  Members agreed that the nature of the injury and the persistent physical/duty limitations in evidence were difficult to reconcile with a 0% rating, and that VASRD §4.40 (Functional loss) was supported to achieve the minimum rating of 10%.  §4.40 states “a part which becomes painful on use must be regarded as seriously disabled,” and there is ample evidence that such was the case with this condition.  Members agreed, therefore, that §4.59 (Painful motion) and/or §4.40 should be conceded in support of a minimum 10% rating for each lower extremity under code 5299-5022.

Despite the diagnosis of medial meniscal tears 8 months after separation, at the time of separation there was no evidence for compensable ROM impairment, frequent effusions, or locking which would support a rating higher than 10% under any applicable code at the time of separation; 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 recommends a disability rating of 10% for both the right and left lower extremity pain conditions.

BOARD FINDINGS:  In the matter of the chronic left lower extremity pain condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5022 IAW VASRD §4.71a.  In the matter of the chronic right lower extremity pain condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5022 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	
Chronic Left Lower Extremity Pain, Due To Tibial Stress Fractures	5299-5022	10%	
Chronic Right Lower Extremity Pain, Due To Tibial Stress Fractures	5299-5022	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

AR20160011860, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

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

Sincerely,

8/17/2016

 

Enclosure
 
XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army
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