RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2015-01500
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20090205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2, Infantryman, medically separated for “right knee pain secondary to a proximal tibial plateau stress fracture,” with a disability rating of 10%.    

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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 IPEB - 20090121	VARD - 20090608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain Secondary to a Proximal Tibial Plateau Stress Fracture	5299-5262	10%	Residuals of Proximal Tibial Plateau Stress Fracture to include Right Knee Strain	5299-5262	0%	20090417	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:    

Right Knee Pain Secondary to a Proximal Tibial Plateau Stress Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in August 2008 after multiple runs, ruck marches and a five foot fall from an obstacle course training apparatus.  X-rays on the right tibia/fibula dated 25 August 2008 demonstrated soft tissue swelling and a questionable medial tibial plateau stress fracture.  X-rays dated 30 September 2008 showed evidence of a healing stress fracture in progress involving the metaphyseal diaphyseal junction (growth plate area).  X-rays of the right knee dated 5 November 2008 demonstrated a healing proximal tibial stress fracture.  At a physical therapy visit on 10 December 2008 the CI complained of right knee joint pain and posterior right lower leg pain, but denied stress fracture pain, although he had mild tenderness to palpation of the medial tibial plateau.  During 11 and 12 December 2008 MEB examinations (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported “stress fractures” and knee pain.  Examination revealed tenderness in the patellofemoral [area] of the right proximal medial tibia.   

The 16 December 2008 MEB NARSUM examination, 2 months prior to separation, noted complaints of right knee pain.  Physical examination revealed tenderness on palpation of the lower extremity along the right proximal medial tibia and patellofemoral (knee/thigh) and superior patellar (kneecap) regions.  The right knee had decreased active flexion, but full passive range of motion (ROM).  Pain was elicited by motion.  There was palpable patellar crepitus on motion of the left knee.  Anterior and posterior drawer signs (to determine laxity) were negative.  Medial and lateral collateral ligaments were stable.  Apley compression and McMurray tests (to determine a meniscal tears) were negative.  A patellofemoral grind test (to detect the presence of a patellofemoral joint disorder) was negative on the right.  There was no swelling, induration, erythema, ecchymosis, warmth, deformity, muscle spasm, muscle atrophy, instability, or weakness of the lower extremity.  Gait and stance were normal.  The right leg was neurovascularly intact distally.

At the 17 April 2009 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported  a history of a right tibial stress fracture and bone pain 3-4 days per week, which was triggered by standing or walking.  He also reported throbbing pain in the knee with ambulation and locking up.  The pain was subpatellar (below the kneecap) and he had rare swelling.  On examination there was a normal gait.  There was no deformity, giving way, instability, weakness, incoordination, or subluxation of the right knee, although crepitation (grinding) was noted.  Locking episodes were reported 3-4 times per week along with repeated effusions.  There were no symptoms of inflammation.  Moderate to severe flare-ups were noted to occur with activity on a weekly basis for 2 hours.  The CI’s impression on the extent of effects of flares on limitation of motion or other function functional impairment was 75%, but the examiner did not comment whether the flare-ups had any effect on limitation of motion.  Flexion was to 130 degrees and extension was 0 degrees without objective evidence of pain with active motion or repetitive motion nor was there any limitation of motion after repetition.  X-ray examination demonstrated numerous linear sclerotic (thickened) striations along the medial aspect distal tibial diaphysis consistent with a medial tibial stress reaction.  There was no acute fracture line or periosteal reaction seen.  An amorphous density in the distal tibial metaphysis laterally and inferiorly most likely represented a fibroma.  Additional vague sclerosis was seen in the proximal tibial metaphysis, which may also have represented a stress injury.  The examiner diagnosed a right tibial stress fracture and right knee strain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, coded 5299-5262 (tibia and fibular, impairment), citing a ROM of 0-120 degrees IAW VASRD §4.10 (functional impairment), §4.40 (functional loss), §4.45 (the joints), and §4.59 (painful motion).  The VA rated the residuals of proximal tibial plateau stress fracture to include right knee strain 0%, coded 5299-5262, based on the C&P examination 2 months after separation, citing absence of malunion of the tibia and fibula with slight knee or ankle disability.  There was a stress fracture of the tibia (5262); however there was no nonunion nor was there malunion proximate to separation since healing was noted on X-rays prior to separation, while post- separation, X-rays favored a stress reaction.  Nevertheless, the condition did not rise to a moderate knee disability to warrant a 20% rating.  Therefore, there was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable 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 right knee condition.  
BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20150611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011806, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,