RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00070
BRANCH OF SERVICE:  Army NATIONAL GUARD 	                         SEPARATION DATE:  20030117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling National Guard E1, Ammunition Specialist Trainee, medically separated for a “stress fracture right tibia” and “myofascial pain syndrome upper thorax,” with a disability rating of 0% and 0%, respectively.  

CI CONTENTION:  The CI requests the Board consider all conditions.  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 on 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 - 20021120	VARD - 20040819	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fracture R Tibia	5099-5003	0%	Residuals Stress Fracture, Left Leg	5099-5022	10%	20031024	
Myofascial Pain Syndrome Upper Thorax	5099-5021	0%	Myofascial Pain Syndrome Upper Thorax	5021	10%	20031024	
Asymmetric Sensorineural Hearing Loss	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Stress Fracture Right Tibia.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right lower extremity condition began in February 2000 without history of trauma during basic training.  Three clinical notes in February and March 2000 documented tenderness at the medial knee (at the tibial plateau); and two entries documented full range of motion (ROM).  Radiographic evaluation in March 2000 documented evidence of a “healing” stress fracture at the proximal right lower extremity (tibia) with documentation of resolution (“no evidence of fracture”) on radiographs obtained in May 2002.  Despite treatment, the right lower extremity tibial stress fracture condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  The MEB forwarded “right proximal tibial stress reaction” for PEB adjudication.  

At the MEB NARSUM examination dated 14 August 2002 (5 months pre-separation), the CI reported constant medial knee pain worsened by running, standing, and walking for long distances.  The physical examination showed normal strength, sensory and neurologic examinations.  ROM measurements were not recorded.  Radiographic evaluations documented a bony callus at the medial tibial plateau with no evidence of acute stress reaction or fracture and no bony abnormality of the right tibia or fibula.  

At the VA Compensation and Pension (C&P) examination dated 24 October 2003 (9 months post-separation), the CI reported weakness, giving way, occasional locking and swelling, and use of assistive devices.  The physical examination showed tenderness at the medial knee, with a ROM of 0-130 degrees (normal 0-140), and no evidence of crepitus, laxity or meniscal injury.  The strength, sensory and neurologic examinations were normal.  Radiographic evaluation documented normal bones, joints and soft tissues.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the “stress fracture right tibia,” analogously coded 5099-5003 (degenerative arthritis) citing full ROM and radiographic evidence of “possible callus formation.”  The VA rated 10% for the “residuals, stress fracture,” analogously coded 5099-5022 (periostitis) citing painful or limited motion of a major joint.  

The Board considered the evidence for a higher rating.  The VA C&P examination was considered to have more probative value as it documented ROMs while the MEB NARSUM did not.  There was no limitation of flexion to 30 degrees (5260) or limitation of extension to 15 (5261) for a higher rating.  Although the examiner did not specifically mention painful motion, there were subjective complaints of pain with evidence of tenderness, reduced ROM, and pre-separation radiographic evidence of stress changes.  Therefore, in consideration of painful motion (§4.59), functional loss (§4.40) and the joints (§4.45), a 10% rating is supported.  There was no evidence of recurrent subluxation or lateral instability for a higher rating under 5257.  Nor was there evidence of meniscal injury with frequent episodes of locking, pain, or effusion for rating.  Also not in evidence were tibia or fibula impairment (5262) with “moderate” knee disability for rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the right tibia stress fracture condition.  

Myofascial Pain Syndrome Upper Thorax.  According to STR and the MEB NARSUM, the CI’s myofascial pain condition began as a result of his knee condition, without history of trauma.  Radiographic evaluation in August 2002 documented lateral curvature of the thoracic spine, “possibly related to muscle spasm” versus idiopathic scoliosis (developmental abnormality).  

At the MEB examination (documented on DD Forms 2807-1 and 2808) dated 12 August 2002 (5 months pre-separation), the CI reported pain in the upper back that caused difficulty sleeping.  The physical examination was checked as “normal.”  

At the August 2002 MEB NARSUM examination, the CI reported the insidious onset of upper back (interscapular paraspinus muscles) pain after returning home from basic training.  He denied weakness and radicular complaints of the upper extremities.  The physical examination showed paraspinal tenderness at the T2-T3 vertebral levels, with no bony tenderness, and full ROM with minimal discomfort.  The strength, sensory and neurologic examinations were normal.  Radiographic evaluation documented a normal spinal curvature without evidence of malalignment or fracture.  

At the October 2003 VA C&P examination, the CI reported daily mid- and lower back pain with morning stiffness worsened by repetitive movement and prolonged sitting.  The physical examination showed normal thoracolumbar curvature, with mid thoracic and lower lumbar tenderness; lumbar flexion was to 40 degrees (normal 90) and bilateral rotation and side bending was to 15 degrees each (normal 30 degrees each).  The strength, sensory and neurologic examinations were normal.  Radiographic evaluation documented degenerative changes, an abnormal curvature (“mild kyphosis”), and a congenital abnormality at the T11 vertebral arch.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the “myofascial pain syndrome, upper thorax,” analogously coded 5099-5021 (myositis), citing no loss of motion, and no radiographic or neurologic abnormalities.  The VA rated 10% for the “myofascial pain syndrome, upper thorax,” coded 5021 (myositis), citing painful or limited motion of a major joint or group of minor joints.  

The Board considered the evidence for rating.  In consideration of painful motion (§4.59), functional loss (§4.40) and the joints (§4.45), there was evidence in support of a 10% rating analogously coded 5099-5021 (myositis).  Alternative codes for a higher rating were considered.  There was no evidence of incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months for a higher rating using the formula for rating intervertebral disc syndrome (5243).  There was no evidence of flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees for a higher rating under the general rating formula for disease and injuries of the spine.   There was no evidence for rating under fibromyalgia (5025), as there was no documentation of widespread (pain in both the left and right sides of the body, both above and below the waist, affecting both the axial skeleton and the extremities) musculoskeletal pain and tender points.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the myofascial pain syndrome, upper thorax condition.  

Contended PEB Condition: Sensorineural Hearing Loss.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The sensorineural hearing loss was profiled as H2 (a “defect that may require some activity limitations”).  However, it was not implicated in the commander’s statement and was not judged to fail retention standards.  All was reviewed and considered by the Board.  There was no performance-based evidence from the record that the sensorineural hearing loss significantly interfered with satisfactory duty performance.  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 contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  
In the matter of the right proximal tibial stress reaction condition, the Board majority recommends a disability rating of 10%, coded 5099-5003IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  

In the matter of the myofascial pain syndrome upper thorax condition, the Board majority recommends a disability rating of 10%, coded 5099-5021 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  

In the matter of the contended sensorineural hearing loss conditions, the Board unanimously recommends no change from the PEB determination 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Proximal Tibial Stress Reaction	5099-5003	10%	
Myofascial Pain Syndrome Upper Thorax	5099-5021	10%	
COMBINED 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150114, 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, AR20170002164 (PD201500070)

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