RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00021
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070315

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Patriot Fire Control Operator, medically separated for “exercise-induced compartment syndrome,” with a disability rating of 0%.  

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 - 20070202	VARD - 20070430	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Exercise Induced Compartment Syndrome	5399-5310	0%	Compression Leg Syndrome with Tarsal Tunnel Impingement, Left Lower Extremity	5299-5262	10%	20070301	
Tarsal Tunnel Syndrome, Right-Sided	Not Unfitting	Compression Leg Syndrome with Tarsal Tunnel Impingement, Right Lower Extremity	5299-5262	10%	20070301	
Patellofemoral Pain Syndrome, Right-Sided	Not Unfitting	Patellofemoral Syndrome and Chondromalacia, Right Knee	5099-5014	NSC	20070301	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Exercise Induced Compartment Syndrome.  The PEB combined the right and left lower extremity exercise induced compartment syndromes as a single unfitting condition analogously coded 5399-5310 (Group X) and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and 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 if 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 DES or be found unfit because of 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 lower extremity exercise induced compartment syndrome conditions are presented, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral lower extremity condition began in February 2003 after running without any history of direct trauma.  At a follow-up visit with orthopedics in November 2003, the CI described symptoms of exertional compartment syndrome with anterolateral leg pain and dorsal foot numbness with activity.  The physical examination showed, painful motion of the foot, normal range of motion and normal gait.  The examiner diagnosed exercise induced compartment syndrome and prescribed a controlled ankle motion (CAM) walker assistive device.  An emergency room visit for right foot pain occurred in November 2004 and radiographic evaluation documented no evidence of fracture, dislocation, arthritic or inflammatory change.  At an orthopedic visit in November 2006, the CI reported right anterior leg pain aggravated by running, jumping and maneuvering stairs.  Physical examination showed a normal gait and tenderness of the middle tibial shaft without swelling.  Despite treatment, the bilateral lower extremity condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral exercise-induced compartment syndrome” for PEB adjudication.  

At the MEB examination on 4 December 2006 (3 months before separation), the CI reported numbness and tingling in the feet.  Physical examination showed tenderness of the anterior lower extremity.  At an orthopedic clinic follow-up visit on 7 December 2006, testing for compartment syndrome was diagnostic for bilateral anterior and lateral compartment syndromes.  Physical examination showed tenderness of the right medial tibial shaft and normal gait.  The examiner diagnosed right lower extremity compartment syndrome, however described that surgical intervention “would entail bilateral anterior and lateral compartment releases.”  Physical therapy ranges of motion (ROM) were performed on 27 December 2006.  Right ankle dorsiflexion was to 4 degrees (normal 20) and left ankle dorsiflexion was to negative 3 degrees.  Both ankles had normal plantar flexion.  There were no limitations due to pain.  

At the MEB NARSUM examination on 28 December 2006, the physical examination showed diffuse tenderness over the anterior and lateral compartments of the bilateral lower extremities. There was discomfort with resisted dorsiflexion and eversion of the foot and ankle.  ROM was documented as 10 degrees (normal 20) of dorsiflexion bilaterally and 40 degrees (normal 45) of plantar flexion bilaterally.  There was normal strength bilaterally.  

At the VA Compensation and Pension (C&P) examination dated 1 March 2007 (2 weeks before separation), the physical examination showed no use of assistive devices, a normal gait and no difficulties with brisk walking.  There was bilateral tenderness of the anterior shins, painful motion, stiffness, no evidence of swelling, and normal knee range of motion bilaterally.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the “bilateral lower leg pain due to compartment syndrome,” analogously coded 5399-5310 (Group X), citing “slight” muscle injury.  The VA granted separate ratings for each “compression leg syndrome with tarsal tunnel impingement” as follows: 10% for the right lower extremity and 10% for the left lower extremity analogously coded 5299-5262 (tibia and fibula, impairment of), and citing functional loss due to pain with no evidence of moderate knee or ankle disability for a higher rating.  

The Board first considered if the right and left compartment syndromes were reasonably justified as separately unfitting (as established above).  In this case, “bilateral leg pain” was profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Members agreed that each compartment syndrome were separately unfitting and that identical coding and ratings are applicable.  

The Board next considered the evidence for rating.  Muscle coding options were considered, but rating would not be advantageous to the member.  Coding analogously to 5262 (tibia and fibula, impairment of) was considered.  There was evidence of slight ankle disability for a 10% rating for each lower extremity.  Coding analogously to 8721, which includes “foot drop” and inability to dorsiflex the foot, would be more consistent with the pathology in this case, and confers a 10% for “incomplete, mild” and 20% for “incomplete, moderate” paralysis.  During compartment testing after provocation, the physical examination showed tenderness of the right middle tibial shaft with normal gait and no mention of weakness.  In consideration of §4.49 (painful motion) and §4.40 (functional loss), the paralysis could be described as “incomplete, mild” as it was aggravated by running, jumping, and maneuvering stairs.  Throughout the STR, clinical examination findings were similar and there was no consistent evidence that one lower extremity was significantly more severe than the other.  Accordingly, Board members concluded that the same rating should apply to each lower extremity.  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 the right and 10% for the left compartment syndromes, analogously coded 8799-8721.  

Contended PEB Conditions: Tarsal Tunnel Impingement, Right-Sided.  The Board’s main charge is to assess the fairness of the PEB’s determination that “tarsal tunnel impingement, right-sided” was not unfitting.  The tarsal tunnel impingement was not specifically profiled, however symptoms attributable to the condition were profiled (L2) in January 2004 as “bilateral ankle pain/foot numbness.”  In January 2007, the profile was generalized to include both the compartment syndromes and the tarsal tunnel impingement as “bilateral leg pain.”  The condition was implicated as “bilateral leg pain” in the commander’s statement and was judged to fail retention standards.  The Board recognized that separate ratings could not be achievable without violation of VASRD §4.14 (avoidance of pyramiding) and therefore, be of no benefit to the CI.  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 fitness determination for the right tarsal tunnel impingement condition, and so no additional disability rating is recommended.  

Patellofemoral Pain Syndrome and Chondromalacia, Right Sided.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not specifically profiled and not specifically implicated in the commander’s statement, however could have been included in the references to the bilateral lower extremity conditions.  It was judged to fail retention standards by the NARSUM examiner, however adjudicated as not unfit by the PEB.  There were no clinical entries and no documentation of symptoms referable to or relating to a knee condition prior to the NARSUM examination nor at the time of the NARSUM.  There was no performance based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral lower extremity exercise induced compartment syndrome conditions, the Board unanimously recommends separate disability ratings as follows: 10% for the right lower extremity and 10% for the left lower extremity analogously coded 8799-8721 IAW VASRD §4.124a.  In the matter of the contended right-sided tarsal tunnel impingement and right sided patellofemoral pain syndrome and chondromalacia conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Lower Extremity Exercise Induced Compartment Syndrome	8799-8721	10%	
Left Lower Extremity Exercise Induced Compartment Syndrome	8799-8721	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150107, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018780 (PD201500021)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA