RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01114
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050301

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E2, Electronic Equipment Repairman, medically separated for “bilateral medial tibial stress fractures” and “left navicular stress fracture,” rated 10% each and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI request review all conditions.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20050114	VARD - 20050307	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Medial Tibial Plateau Stress Fractures	5299-5262	10%
10%
20%	Right Medial Tibial Plateau Stress Fracture	5262	0%	STR
	
			Left Medial Tibial Plateau Stress Fracture	5262	0%		
Left Navicular Stress Fracture	5299-5279	0%	Left Navicular Stress Fracture		NSC		
Bilateral Knee Patellofemoral Pain Syndrome	Cat III	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Medial Tibial Plateau Stress Fractures (Fxs).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral medial tibial stress fxs condition began in October 2004 during basic training, 5 months before separation.  The CI reported bilateral knee pain and a bone scan performed on 19 October 2004 showed bilateral medial tibial plateau (knee) stress fxs.  A repeat bone scan performed on 3 December 2004, 3 months before separation, showed the medial tibial plateau (MTP) stress fxs again, but with decreased uptake “suggestive of healing process.”  

The 15 December 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of being unable to run more than a quarter mile, or walk or stand for prolonged periods of time without bilateral lower extremity pain.  Physical examination showed a normal gait.  The examination was reported for the bilateral knees.  There was no swelling or effusion.  Knee range of motion (ROM) was 0 degrees extension (normal 0) and 130 degrees flexion (normal 140).  Testing for patellofemoral syndrome was negative (negative inhibition).  There was no tenderness to palpation (TTP) of the patellar structures.  There was no evidence of instability or meniscal injury.  There was no TTP of the femoral bone at the knee joint.  There was TTP of the MTP bilaterally and the right tibial shaft.  There was no swelling or bruising.  Bilateral knee X-rays were normal.  A repeat bone scan showed changes consistent with a history of MTP stress fxs.  The NARSUM indicated the CI’ multiple stress fxs interfered with the reasonable performance of her duties.  

At the 20 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, physical examination showed TTP of the knees, medially more than laterally.  
The 13 January 2005 JDETS, 2 months before separation, indicated the CI was unfit due to the bilateral MTP stress fxs and the left navicular stress fx.  The 16 December 2004 Non-Medical Assessment implicated the CI’s multiple stress fxs and overuse syndrome of both knees as impairing successful performance of the duties of her Rate.  

At the 7 December 2005 VA Compensation and Pension (C&P) Joints evaluation, 9 months after separation, the CI reported she did not use any type of knee brace.  She reported bilateral knee pain, aggravated by standing or walking for an hour or stair climbing and improved by rest.  The pain was bilateral, located at the bottom of the kneecap and the medial aspect of the tibia.  Physical examination showed a normal gait.  There was no evidence of uneven weight bearing.  Balance on one foot was normal bilaterally.  The CI was able to heel and toe walk and squat without difficulty or pain.  The right and left knee examinations were reported separately, but were essentially the same.  There was no tenderness, swelling or effusion of the right knee.  There was TTP of the proximal tibia on the right, especially medially.  There was no evidence of instability or meniscal injury.  The patella was not displaced or TTP.  Right knee ROM was 0 degrees extension and 130 degrees flexion, with no painful motion or crepitus.  There was no additional loss of ROM with repetitive motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated bilateral medial tibial stress fxs, and assigned a 10% for the right and 10% for the left MTP stress fxs, both coded 5299-5262 (analogous to tibia and fibula impairment).   The original VA Rating Decision rated the right and left MTP stress fx conditions 0% each, both coded 5262, citing the CI failed to attend a scheduled C&P examination in February 2005.  The 9 February 2006 VARD continued the 0% ratings for both right and left MTP stress fxs, based on the VA C&P examination 9 months after separation, citing “absence of malunion of the tibia and fibula with slight knee or ankle disability.”
  
The panel reviewed the records to see if a higher rating was supported for either the right, left, or both MTP stress fxs.  There was no evidence of knee or ankle disability that could be characterized as moderate for higher rating under 5262 for either MTP stress fx.  There is therefore no higher rating than 10% for an individual major joint and no higher than 20% combine rating for two or more major joints with imaging evidence of pathology analogous to degenerative arthritis under 5003 (degenerative arthritis).  There was no limitation of motion which supported higher rating under the diagnostic codes for limitation of knee flexion or extension (5260, 5261) or limitation of ankle motion (5271) for either MTP stress fx.  There was therefore no higher than 10% rating available for either MTP stress fx condition under any applicable VASRD code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for either of the bilateral medial tibial stress fxs conditions.  

Left Navicular Stress Fracture.  According to the STR and the MEB NARSUM, the CI’s left navicular stress fx condition began in September 2004 after a twisting injury to the left ankle, 5 months before separation.  The CI reported sharp shooting pain from her ankle to her knee with walking.  Left ankle X-rays performed on 23 September 2004 were negative and a bone scan performed on 19 October 2004 showed a stress fx of the left navicular bone.  A repeat bone scan on 3 December 2004, 3 months before separation, showed the left navicular stress fx with decreased uptake “suggestive of healing process.”  

The 15 December 2004 MEB NARSUM examination, 3 months prior to separation, noted no specific complaints regarding the left ankle/foot.  Physical examination showed bilateral ankle ROM of dorsiflexion 20 degrees (normal 20) and plantar flexion 40 degrees (normal 45).  There was no swelling, TTP or instability of either ankle.  There was no TTP of the midfoot or metatarsals.  Strength, sensation, reflexes, and pulses were normal.  

At the 7 December 2005 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported she had no complaints with her feet.  She did not use any type of ankle brace.  Physical examination showed a normal gait.  There was no evidence of uneven weight bearing.  Balance on one foot was normal bilaterally.  The CI was able to heel and toe walk and squat without difficulty or pain.  The right and left ankle examinations were reported separately, but were essentially the same.  There was no tenderness, swelling, or effusion.  There was no evidence of instability.  There Achilles tendons and feet were in normal alignment.  There were no calluses or toe deformities.  There was no painful motion demonstrated and there was no change in ROM with repetitive motion.  Right ankle ROM was dorsiflexion 20 degrees and plantar flexion 45 degrees.  The left ankle ROM was 20 degrees dorsiflexion, with no plantar flexion specifically noted, but immediately following the DF, the examiner indicated that the CI had no complaints of pain “with any of these range of motion.”  As noted above, there were no vascular or neurological abnormalities of the ankle or foot.  Bilateral foot X-rays were normal.  A repeat bone scan showed degenerative/post-traumatic changes of both ankles, right greater than left.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left navicular stress fx condition 0%, coded analogously to 5279 (metatarsalgia).  The original VARD rated the residuals, left navicular stress fx condition 0% coded 5284 (foot injuries, other), citing the CI failed to attend a scheduled C&P examination in February 2005.  The 9 February 2006 VARD continued the 0% rating, based on the VA C&P examination 9 months after separation, citing absence of moderate symptoms associated with foot injury. There was no evidence of pain of a metatarsal joint or joints for a 10% rating under 5279.  There was no limitation of motion which supported higher rating than 0% under the diagnostic code for limitation of ankle motion (5271).  There was no evidence of “moderate” symptoms associated with foot injury for higher rating under 5284.  There was no evidence of tarsal or metatarsal nonunion or malunion (5283) for consideration of rating under this code.  The panel considered alternative VASRD ankle, foot, and analogous codes, but all were less applicable.  There was therefore no higher than a 0% rating under any alternative VASRD code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left navicular stress fx condition.  

Contended PEB Conditions: Bilateral Knee Patellofemoral Pain Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The bilateral PFPS was the initial diagnosis provided for the CI’s bilateral knee pain.  However, after the bone scan was performed the diagnosis of the knee pain was bilateral MTP stress fxs and no further diagnosis of PFPS was noted in the STR.  The JDETS determined the CI was unfit due to the stress fxs of the MTPs and the left navicular bone.  The NMA did implicate multiple stress fxs and overuse syndrome of the knees and the NARSUM listed both diagnoses of the bilateral knees.  However, there was no performance-based evidence from the record that the PFPS condition of either knee significantly interfered with satisfactory duty performance at separation when considered apart from the MTP stress fxs, nor were any physical findings of PFPS documented by the MEB or VA examiners which would be associated with significant disability.  Therefore, the panel concluded that there was not a preponderance of evidence that supported the bilateral PFPS condition would have caused the CI to be referred into the DES or to be found unfit.  Additionally, any disability due to PFPS of either knee was not separable from the disability due to the MTP stress fxs, either for fitness or rating, and is subsumed in the panel’s rating recommendation for the MTP stress fxs IAW §4.71a and §4.14 (avoidance of pyramiding).  After due deliberation, the panel 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 medial tibial stress fxs” conditions and the left navicular stress fx condition IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications.  In the matter of the contended bilateral knee patellofemoral pain syndrome condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, 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

      In accordance with reference (a), I have reviewed the cases listed below and 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:

		- XXXXXXXXXXXXXXXXXX

		- XXXXXXXXXXXXXXXXXX former USMC
	 	- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC