RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00571
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Military Police, medically separated for “bilateral tibial plateau stress reactions,” with a disability rating of 0%.  

CI CONTENTION:  The CI requested the board review 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 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 - 20020418	VARD - 20030616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Tibial Plateau Stress Reactions	5099-5022	0%	Bilateral Tibial Stress Reactions with Pain in Bilateral Ankles and Knees	5299-5262	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:    

Bilateral Tibial Plateau Stress Reactions.  The PEB combined the bilateral tibial plateau stress reaction conditions under a single Service disability rating, analogously coded 5099-5022 (periostitis) 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 also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 Disability Evaluation System 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 tibial plateau stress reaction conditions are presented, with attendant recommendations regarding separate unfitness, and separate rating if indicated

According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral tibial plateau stress fractures began shortly after initial training, without specific injury or trauma.  At a physical therapy (PT) appointment in February 2002 (3 months before separation), the CI reported pain with running, walking and sitting.  The physical examination showed an antalgic gait, tenderness over the medial tibial plateaus, and bilateral range of motion (ROM) of 0-130 degrees (normal 0-140).  Radiographic studies (X-rays) documented stress fractures of the bilateral proximal tibias (at the medial tibial plateaus).  At a follow-up PT visit in March 2002 (2 months before separation), the CI reported decreased pain, however pain continued with walking.  Physical examination revealed a normal gait, tenderness over the medial tibial plateaus, and bilateral ROM of 0-130 degrees.  At an orthopedic clinic visit 4 days later, physical examination showed tenderness over the medial tibial plateaus, full bilateral ROM and no evidence of instability.  Further imaging (bone scan) in March 2002 revealed bilateral medial tibial plateau stress fractures.  Despite treatment, the bilateral tibial plateau 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 medial tibial plateau stress fractures” for PEB adjudication.  

At the MEB NARSUM examination performed on 25 March 2002, the CI reported pain with running, jumping, marching, bending, and squatting activities.  The physical examination showed tenderness at the medial tibial plateaus, full ROM, with no evidence of effusion or ligamentous instability.  The bilateral tibial plateau stress fractures were profiled in April 2002.  The Commander’s statement was not in evidence.  

The CI failed to attend the scheduled VA Compensation and Pension (C&P) evaluation.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the bilateral tibial plateau stress reactions condition 0%, coded analogously to 5022 (periostitis), citing full range of motion without instability.  The VA rated 0% for the “bilateral tibial stress reactions with pain in bilateral ankles and knees” condition, analogously coded 5299-5262 (tibia and fibula, impairment of) citing a non-compensable rating was assigned in the absence of malunion of the tibia and fibula with slight knee of ankle disability.  

The Board first considered if either knee condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  In this case, both knees were considered to fail retention standards; and, both were implicated by the NARSUM.  The bilateral condition was permanently profiled with limitations that would have resulted from either condition alone.  Members agreed that the left and right tibial stress fractures, as isolated conditions, would have each rendered the CI incapable of continued service for his MOS and accordingly, separate Service ratings could be recommended.  

The Board next considered the rating recommendation.  There was no evidence of painful motion with functional loss in either knee in support of a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  The bilateral tibial plateau stress fractures could be analogously coded under the codes for knee impairment related to long bone conditions (5255 or 5262), however, there was no evidence of “slight knee or ankle disability” in support of a higher rating.  No additional functional limitation was evidenced by the examinations.  A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that none of the examinations in evidence provided satisfactory evidence for painful motion of either knee; thus, separate joint ratings are not indicated IAW §4.71a and would 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 adjudication for the bilateral tibial plateau stress reactions condition.  

BOARD FINDINGS:  In the matter of the bilateral tibial plateau stress reactions 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 20150604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018762 (PD201500571)

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, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA