RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00795
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20050323

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Fire Protection Craftsman, medically separated for “chronic left leg pain secondary to tibia/fibula fracture” with a disability rating of 10%.  

CI CONTENTION:  The CI requests the Board 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 confined to 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 - 20041203	VARD – No VA Disability Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Leg Pain secondary to Tibia/Fibula Fracture	5262	10%	No VA evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Left Leg Pain secondary to Tibia/Fibula Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left leg condition began in August 2002 after trauma.  The CI underwent surgery with intramedullary nailing (IM) in August 2002, and due to delayed union underwent a second surgery with left tibial nail exchange in March 2003.  Following surgery and despite further treatments, the CI continued with left lower leg pain without improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left leg pain following tibia and fibula fracture and IM nail” for PEB adjudication.  

Specialty evaluation dated November 2004 noted complaints of 4/10 pain with dullness of the left ankle fracture site.  The CI reported left leg weakness and questionnaire indicated 10% severity with the CI indicating a 50% reduction in his ability to do everyday activities.  Examination documented full range of motion of the extremities with tenderness at the left fracture site.  Neuroactive medication (Gabapentin) was added and the diagnosis was fibromyalgia or myofascial syndrome with neuropathic pain on left lower extremity.  

At the NARSUM examination dated August 2004, 8 months prior to separation, the CI reported constant burning pain 3/10 along the tibial border of his left leg (front and inner calf area), which would increase to 7/10.  He also described knee pain and tightness with a sensation that his knee would pop, but the knee never did.  Medications did not significantly help the pain.  Diagnosis was chronic pain with a healed fracture.  Physical exam showed slight decreased touch sensation in the left mid-calf area and on the top and middle side of the left foot.  Strength in the legs was 5-/5 (slight weakness) on the left quadriceps, hamstring, and tibialis anterior, and 5/5 (normal) in all other lower extremity muscles.  Reflexes were normal and symmetric.  The examiner stated that the most recent X-rays of the left tibia and fibula noted a healed distal diathesis fracture unchanged from prior studies.  

There was no VA evidence in the record and the CI’s application indicated that he had not submitted a VA Disability Claim.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5262 code (tibia and fibula, impairment), citing a lack of objective findings and a fairly benign physical examination.  There was no significant muscle injury for alternate muscle rating IAW VASRD §4.73 (schedule of ratings–muscle injuries).  Potential rating under a peripheral nerve code (for neuritis/neuropathic pain IAW VASRD §4.124a) would not provide for any rating higher than the 10% awarded by the PEB.  There was no record of significant limitation of motion or laxity of the knee or ankle joint that supported a rating under the VASRD diagnostic codes for limitation of motion or instability of either joint.  

The Board deliberated on the 5262 rating criteria.  There was no indication of nonunion or loose motion of the tibia/fibula and therefore the Board directed attention to “knee or ankle disability” at the “slight” (10%), “moderate” (20%) or “marked” (30%).  Given the documented post-fracture repair complaints of lower leg pain and neuropathic pain, and the physical findings of slight muscle weakness and sensory deficits, the Board adjudged that the CI’s disability picture at separation most closely approached the “moderate” criteria under tibia and fibula impairment (5262).  No higher rating was supported under any peripheral nerve rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left leg condition, coded 5262.  

BOARD FINDINGS:  In the matter of the left leg condition, the Board unanimously recommends a disability rating of 20%, coded 5262 IAW VASRD §4.71a and §4.124a.  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	
Chronic Left Leg Pain secondary to Tibia/Fibula Fracture	5262	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00795.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachments:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR