RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00074
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20030915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “left tibia and fibula fracture” and “left superficial peroneal neurapraxia,” 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 – 20030727	VARD - 20040128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Tibia and Fibula Fracture	5299-5003	10%	Residuals, Fracture Left Tibia/Fibula…	5262	20%	20040225	
Left Superficial Peroneal Neurapraxia	8722	10%	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Tibia and Fibula Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a left lower extremity injury approximately 3 years prior to referral for MEB.  The MEB forwarded “closed fracture of unspecified part of fibula with tibia” and injury to peroneal nerve” for PEB adjudication.  

The MEB NARSUM examination on 27 May 2003, 4 months before separation, documented the CI sustained a left closed tibia and fibula fracture on 23 March 2000 during fast-roping exercises.  On 24 March 2000 he underwent left tibia intramedullary nailing and placement of a syndesmosis (fibrous connective tissue joint with adjacent bones united by interosseous membrane) screw to treat the distal fibula fracture.  The syndesmosis screw was removed in October 2000.  The CI experienced a delayed union of the tibia and in February 2002 the interlock screws were removed from the tibial nail.  The tibia fracture ultimately healed however, the tibia and the fibula healed together.  On 22 August 2002, he underwent removal of the tibial nail and excision of synostosis (fusion of adjacent bones).  No ancillary treatment was used to prevent recurrence of heterotopic ossification ([HO] abnormal bone growth in non-skeletal tissues) and the space between the tibia and fibula filled in yielding a synostosis.  The left lower extremity examination revealed a well healed wound in the distal third of the anterolateral leg.  Light touch sensation was decrease in the dorsum of the foot and there was 4/5 peroneal muscle strength.  A left lower extremity X-ray revealed well-healed tibia and fibula fractures, ossification of the syndesmosis between the tibia and fibula, and no retained hardware.  A left ankle X-ray revealed near anatomic alignment of the tibia, a slightly shortened fibula and mild arthrosis (joint degenerative disease) in the ankle joint.  The impression listed left tibia and fibula fractures.  A 15 July 2003 orthopedic surgery left lower extremity examination documented left ankle active range of motion (ROM) was dorsiflexion of 25 (20 normal), plantar flexion of 45 (45), eversion of 5 (20), and inversion of 30 (30) degrees.  

At the 25 February 2004 orthopedic VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI complained of daily 4/10 left leg pain which was aching and sharp.  He reported slight occasional swelling and a slight limp with no ambulatory aids.  The CI complained of 2/10 left ankle pain with occasional swelling and slight tightness.  He occasionally used an air cast type ankle brace.  Pain was exacerbated by prolonged walking and there was no current treatment.  The physical examination documented a very slight limp on the left.  The left lower extremity examination reveal 3 well healed scars.  The anterolateral scar at the distal third of the leg was tender and there was slight swelling of the lower leg.  The left ankle examination revealed no tenderness or swelling.  Ankle active ROM was dorsiflexion of 5 (20), plantar flexion of 45 (45), eversion of 15 (20), and inversion of 30 (30) degrees with slight pain at terminal degrees.  Strength was plantarflexion of 5/5 and dorsiflexion of 4/5.  The impression listed “Left lower leg:  Diagnosis deferred pending X-rays today -- history of fracture with open reduction and internal fixation and removal of hardware.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) for left tibia and fibula fracture.  The VA assigned a 20% rating under the 5262 code (tibia and fibula, impairment of) based on the VA C&P orthopedic examination 5 months after separation, citing the CI failed to report for the VA C&P neurological examination.  The VA also cited pain on motion with a slight reduction in ROM which was considered moderate.  While the CI underwent multiple left leg surgeries, X-rays showed well-healed tibia and fibula fractures, near anatomic alignment of the tibia, and a slightly shortened fibula.  There was no deformity for consideration under code 5262 (tibia and fibula nonunion/malunion) or 5263 (genu recurvatum).  While X-rays showed mild arthrosis in the ankle joint, there was no deformity for consideration under code 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis), 5273 (os calcis or astragalus, malunion), or lower extremity bones shortening (5275).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  The orthopedic surgery examination documented left ankle dorsiflexion of 25 (20 normal), plantar flexion of 45 (45), eversion of 5 (20), and inversion of 30 (30) degrees.  The VA C&P examination documented left ankle dorsiflexion of 5 (20), plantar flexion of 45 (45), eversion of 15 (20), and inversion of 30 (30) degrees.  Board members agreed that the ROM values more closely approximated the moderate (10%) than the marked (20%) rating under 5271 (ankle, limited motion of).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 for the left leg condition.  
Left Superficial Peroneal Nerve Condition.  According to STR and MEB NARSUM, the CI sustained a left lower extremity injury approximately 3 years prior to referral for MEB.  The NARSUM recounted the history and interventions.  The CI had had significant pain since the time of injury and had never been pain-free.  With physical therapy (PT), he had progressed from a controlled ankle motion (CAM) walker, to a regular shoe with an ankle brace.  After the 22 August 2002 tibial nail removal and synostosis excision, the CI experienced regional pain, painful “electrical shocks” into the foot, and decreased light touch on the foot dorsum, concerning for nerve injury.  On 28 January 2003 he underwent exploration of the lateral wound neuroma (reactive tumor of disorganized axons) with excision of scar tissue and superficial peroneal nerve release.  The procedure revealed a neuroma in continuity (reactive disorganized axons tumor in continuity and intermixed with nerve fibers) and that the nerve was not severed.  The left lower extremity examination revealed a well healed wound in the distal third of the anterolateral leg.  There was a positive Tinel’s sign (percussing nerve elicits tingling over distribution of the nerve) at the wound.  Light touch sensation was decrease in the dorsum of the foot and there was 4/5 peroneal muscle strength.  The surgeon injected local anesthetic in the area of the Tinel’s sign which produced a 40% decrease in pain indicating that some of the pain was coming from the injured superficial peroneal nerve.  At the time of examination, the CI was still contemplating treatment for the neuroma (chemical or surgical) to try and decrease pain coming from this area.  The impression listed left superficial peroneal neurapraxia (temporary loss of peripheral nerve motor and sensory function due to conduction blockage).  The surgeon documented “The peroneal muscles are not terribly functional.  This is probably due to the injury in the local area and the scarring of them, losing excursion as the muscles fire fine and there is no evidence of higher peroneal nerve injury.  The issue with the peroneal nerve neurapraxia is going to be up to the member.  If he wishes to be more aggressive about treating this.  It will not resolve his problem or eliminate all of his pain, but may make him a little more functional…”  A 15 July 2003 orthopedic surgery preoperative evaluation documented a plan to cut the superficial peroneal nerve, excise the neuroma in continuity, and bury the nerve end to attempt pain relief.  The left lower extremity examination revealed a positive Tinel’s sign at the proximal incision.  Overall strength was 5/5 except for 4+/5 peroneals.  Sensation was normal except for decreased light touch on the dorsum of the foot. On 15 July 2003 the CI underwent a superficial peroneal nerve transection with excision of the neuroma in continuity.  The 4 August 2003 orthopedic surgery follow-up documented decreased pain, and decreased sensation on the dorsum of the left foot, as expected.  In the C&P examination the CI complained of left foot numbness which started after surgery to remove the internal fixation hardware.  The examiner documented “Neurology ratings examination ordered for complaint of numbness, left foot, which he stated presented after his 2003 surgery to remove the internal fixation hardware from the left leg.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 8722 code (musculocutaneous nerve [superficial peroneal] neuralgia) for left superficial peroneal neurapraxia.  The VA did not service-connect the left superficial peroneal neurapraxia based on the VA C&P orthopedic examination 5 months after separation and noted that the CI failed to report for the VA C&P neurological examination.  The Board noted the CI underwent a superficial peroneal nerve transection, with excision of the neuroma in continuity, 6 weeks after the NARSUM.  The 2-week postoperative follow-up noted improvement and documented decreased pain, and decreased sensation on the dorsum of the left foot, as expected.  Peripheral neuralgia are usually characterized by dull and intermittent pain, of typical distribution so as to identify the nerve.  The neuralgia codes rate based on an assessment of functional impairment expressed in terms of severity of paralysis.  The neuralgia code (8722) is limited to a maximum of moderate incomplete paralysis (§4.124) which is a 10% rating.  Board members agreed that there was sufficient evidence of pain with use to support a 10% rating considering VASRD §4.40 (functional loss) and §4.59 (painful motion).  Members agreed that findings were concordant with moderate incomplete paralysis, consistent with a 10% rating under 8722.  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 for the left leg neuralgia condition.  

BOARD FINDINGS:  In the matter of the left tibia and fibula condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left superficial peroneal nerve condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 , 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 Oct 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 USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC

						  XXXXXXXXXXXXXXXXXXXX
	     				               Assistant General Counsel
						  (Manpower & Reserve Affairs)