RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01538
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090605

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E3, Combat Medic Trainee, medically separated for “bilateral tibial stress reactions,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  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 - 20090501	VARD – 20100120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Tibial Stress Reactions	5299-5262	10%	Residuals, Stress Fracture Left Leg	5099-5020	0%	20091118	
		10%	Residuals, Stress Fracture Right Leg	5099-5020	0%	20091118	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Tibial Stress Reactions.    According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral tibial stress reaction condition began in August 2008 without any specific injury or trauma. Treatment consisted of ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) and tramadol, an opioid-like medication.  Pain, which was originally in the knees, persisted, but in November 2008 the pain was accentuated in the shins.  A bone scan dated 13 January 2009 revealed a stress fracture of the right medial tibial plateau and severe stress changes to the left medial tibial plateau, a Grade I stress fracture of the left tibia and focal stress changes on the right.  Stress changes were also noted in the ankles and feet.  Physical therapy was instituted for crutches, gait training, and pool rehabilitation.  X-rays dated 5 February 2009 showed a subtle, mature, smooth periosteal reaction along the medial distal tibia shaft on the left.  On the right the known stress changes involving the medial tibial plateau were not appreciated radiographically.  The CI reported her pain with a severity of 2/10 (10 being the worst pain) that was localized to the anterior medial aspect of both legs and was worse with all impact activities.  

Despite treatment, the bilateral tibial stress reactions 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 tibial stress fractures” for PEB adjudication.  

During the 17 March 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported she had bilateral stress fractures and could not perform at her optimum.  Physical examination showed a full range of motion (ROM) of the knees with tenderness to palpation of the bilateral medial tibial plateaus and no edema.  The 17 March 2009 MEB NARSUM examination, 3 months prior to separation, noted complaints of continued leg pain and symptoms refractory to physical therapy rehabilitation, temporary profiles, various pain medications, crutches, and convalescent leave.  Physical examination showed the CI had a non-antalgic gait.  There was no edema, erythema, ecchymosis, or obvious deformity of either leg.  There was mild tenderness to palpation over the medial tibial plateaus and the proximal 1/3 of both tibial shafts without crepitation or deformity noted.  All lower leg compartments were supple and non-tender.  

At the 21 November 2009 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported her knee joints and legs bothered her only after walking greater than one mile or standing more than 30 minutes.  Examination of the left knee revealed no deformity, giving way, instability, stiffness, weakness, incoordination, subluxation, or effusion.  She did note pain, decreased speed of joint motion, warmth, swelling, and tenderness.  Her right knee had no deformity, instability, pain, stiffness, weakness, incoordination, decreased speed of joint motion, subluxation, locking, effusion or symptoms of inflammation, but there was giving way.  She reported mild weekly flare-ups bilaterally precipitated by standing or walking that were alleviated by rest or ice.  Her gait was normal with crepitation on the right and none on the left.  There were no clicks, snaps, grinding, or instability, and there were no patellar, meniscal, tendons or bursae (fluid filled sacs about the knee) abnormalities.  Flexion of the left and right knees each was 140 degrees and extension 0 degrees.  There was no pain with active motion of either knee and there was no limitation of motion with repetition.  There was no ankylosis, tenderness or swelling of the anterior legs.  X-rays dated 18 November 2009 of the right and left tibia and fibula showed no evidence of any fractures, dislocations, lytic or blastic (malignant or infections) lesions.  Periosteal (outer layer of bone) reactions, soft tissue masses or abnormal calcifications were not seen.  The X-ray findings were within normal limits and there was no bony or soft tissue pathology.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral tibial stress reactions condition 20% (left 10% and right 10%), coded 5299-5262 (tibia and fibula, impairment), citing diagnosis by bone scan and functional loss considered under VASRD 4.10 (functional impairment), 4.40 (functional loss), 4.45 (the joints), and 4.59 (painful motion).  The VA rated the residuals, stress fracture of the left leg condition 0%, coded 5099-5020 (synovitis), based on the VA C&P examination 5 months after separation, citing subjective symptoms only with no objective evidence of painful or limited motion of the left leg.   The VA rated the residuals, stress fracture of the right leg condition 0%, coded 5099-5020 (synovitis), based on the C&P examination 5 months after separation, citing subjective symptoms only with no objective evidence of painful or limited motion of the right leg.  Panel members noted there was a fracture and stress changes of the lower extremities, which in follow-up prior to separation showed a subtle, mature, smooth periosteal reaction along the medial distal tibia shaft on the left; and, on the right the known stress changes involving the medial tibial plateau were not appreciated radiographically, while by 5 months post-separation X-ray finding were with normal limits.  Additionally, the CI had a non-antalgic gait with no more than mild knee disability marked by mild tenderness to palpation over the medial tibial plateau and the proximal 1/3 of both tibial shafts without crepitation and a full ROM prior to separation and no objective findings 5 months after separation.  Therefore, neither leg condition rose to the level of a moderate disability.  Thus, there was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB for each lower extremity under any applicable code related to limitation of flexion or extension (5260, 5261), instability or laxity (5257), meniscal surgery (5259), or frequent locking with effusions (5258).   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 bilateral tibial stress reactions condition.  

BOARD FINDINGS:  In the matter of the bilateral tibial stress reactions 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150613, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008818, XXXXXXXXXXXXXXXXXX 

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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,					       
						      					
Enclosure