RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01530
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030306

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Motor Transport Operator, medically separated for “bilateral medial tibial plateau stress fractures” with a disability rating of 0%.

CI CONTENTION:  “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 - 20030218	VARD - 20030611	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Medial Tibial Plateau Stress Fractures (and MEB diagnosis #3:  Bilateral Femoral Stress Reaction)	5099-5003	0%	Medial Tibial Plateau Stress Fractures, with Capsular Contraction of the Knee Joint and previous Femoral Shaft Stress Reaction, Right Lower Extremity	5299-5262	10%	20030424	
			Medial Tibial Plateau Stress Fractures, with Capsular Contraction of the Knee Joint and Previous Femoral Shaft Stress Reaction, Left Lower Extremity	5299-5262	10%		
Hamstring Contractures secondary to loss of some Knee Extension	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Bilateral Medial Tibial Plateau Stress Fractures (and MEB Diagnosis #3:  Bilateral Femoral Stress Reaction).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral stress fractures condition began in September 2002 after an overuse injury during basic combat training.  The CI had pain in both knees with swelling of both legs from the knees to the ankles.  Diagnostic imaging supported clinical findings of bilateral tibial stress fractures and also showed mild bilateral femoral stress reactions.  The CI was considered to have a poor prognosis for return to duty, was placed on convalescent leave for recovery, and referred for MEB.

The 2 and 12 December 2002 Physical Therapy evaluations documented an antalgic gait, as did the physical therapy evaluation on 6 January 2003.  The 13 January 2003 MEB NARSUM examination, 2 months before separation, noted complaints of bilateral knee pain left greater than right.  Physical examination showed some tibia vara below her knees (out bowing of legs).  Hip range of motion (ROM) was full and symmetric without any significant recreation of any pain.  Left knee ROM was left 5-135 degrees (normal 0-140) and right knee was 0-135 degrees.  There was no pain with resisted:  knee flexion or knee extension.  There was no knee crepitus, laxity, or instability, and patellar glide was normal.  Both medial tibias were tender and the “popliteal angles are approximately 30 degrees, which is significant for some hamstring contractures.”  The ankles were without effusion or erythema, and no ankle deficits were noted.

At the 24 April 2003 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported bilateral knee pain and limited motion with fatigue and lack of endurance.  She indicated swelling of her lower legs had resolved, and denied knee instability, knee locking, or hip joint pain.  Physical examination showed normal posture with an abnormal gait, “when she walks she does not fully extend her right knee and extends about 170 degrees.  There is also a genu varus [bow legs] deformity of her legs with standing.”  There was no significant swelling in the knees and no evidence of Baker cyst (fluid-filled cyst behind the knee causes bulge or tightness).  The CI had difficulty with squatting difficulty getting down and up and only flexed her knees approximately 90-95 degrees.  There was crepitus with knee flexion and extension.  Laxity (instability) was present.  Formal bilateral knee ROM was performed on 20 May 2003 (C&P addendum) showing extension to flexion of 5-125 degrees.  Bilateral hip ROM was “good” with no pain detected.  There was no pain with motion of the ankles.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral tibia stress fracture condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing confirmed by X-ray and bone scan.  The VA rated the left and right lower extremity stress fractures 10% each, analogously coded 5299-5262 (tibia and fibula, impairment), based on the C&P examination 2 months after separation, citing malunion of the tibia and fibula with slight knee or ankle disability.

The panel 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.  This 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.

The panel’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 panel 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 DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

The profile indicated bilateral tibial stress fractures with limitations, the MEB NARSUM indicated poor prognosis for return to duty due to bilateral tibial stress fractures, and the MEB adjudged the bilateral tibial plateau stress fractures did not meet retention standards.  There was no commander’s statement in evidence.  STR notes addressed bilateral knees/tibias without significant differences between the slightly more severe left side and the right side.  The panel majority concluded that there was not a preponderance of evidence to overcome the panel’s presumption that either of the bundled left and right tibial stress fracture condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting left and unfitting right tibial stress fracture conditions at the time of separation.

There was evidence of bilateral femoral shaft stress reactions with no evidence of hip disability.  Therefore, any disability from the bilateral femoral shaft stress reactions is also considered in rating the knees (and cannot be additionally rated IAW VASRD 4.14 (avoidance of pyramiding)).  There were bilateral stress fractures of the tibia to support consideration under code 5262 (tibia and fibula, impairment).  The panel deliberated if there was sufficient evidence of “slight knee or ankle disability” at separation to warrant a 10% rating for each side.  All examinations proximate to separation documented slight limitation of knee ROM and no ankle deficits.  The examinations provided mixed evidence with no painful motion at the MEB NARSUM or physical therapy examinations, and painful squatting at the VA examination; the panel also considered that all physical therapy examinations following convalescent leave, as well as the proximate VA examination, showed an abnormal gait, and that the MEB NARSUM was silent regarding gait.

Members’ consensus was that the evidence supported slight knee disability for separate 10% ratings for each knee under code 5299-5262.  There was no limitation of motion which supported a 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.  There was therefore no VASRD §4.71a route to a rating higher than the 10% under code 5299-5262.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the left tibial plateau stress fracture condition, and a disability rating of 10% for the right tibial plateau stress fracture condition each coded 5299-5262.

Contended PEB Conditions:  Hamstring Contractures secondary to loss of some Knee Extension.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or judged to fail retention standards.  The condition affects, or can affect, the knee joint and could be rated based on knee disability.  However, any disability of the knee joints was considered in the unfitting bilateral knee condition above and the contended condition cannot be additionally rated IAW VASRD 4.14 (avoidance of pyramiding).  There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended conditions and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the bilateral tibial plateau stress fractures condition, the panel majority recommends that each tibia be separately adjudicated as follows: an unfitting right tibial plateau stress fractures condition coded 5099-5262 and rated 10%, and an unfitting left tibial plateau stress fractures, coded 5099-5262 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended hamstring contractures secondary to loss of some knee extension condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Right Tibial Plateau Stress Fractures	5299-5262	10%	
Left Tibial Plateau Stress Fractures	5299-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008573, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXXXX.

Sincerely,	
Enclosure