RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02442
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Systems Organizational Apprentice Maintenance Technician, medically separated for “open right tibia fracture” and “post phlebitic syndrome,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contends the ratings for his tibia fracture, feet, pulmonary emboli, asthma, knee pain, lower back pain and hip pain.  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 progression or complications of service-connected conditions after separation.  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 - 20060628	VARD - 20071210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Open Right Tibia Fracture	5299-5003	10%	Residuals, Fracture, Right, Tibia	5262	0%	20070929	
			Residuals, Scar	7802	0%		
Post Phlebitic Syndrome	7101	10%	Post Phlebitic Syndrome	7121	NSC		
PFS	Cat II	No VA Placement	
Pulmonary Embolism		Residuals, Embolism with Infarction	7199-7114	NSC	20070929	
Right Hallux Valgus…	Cat III	Bilateral Hallux Valgus	5280	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Open Right Tibia Fracture and Category II Patellofemoral Pain Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI fell 6-10 feet from a boat dock on 25 June 2005 and sustained an open fracture of the right tibia.  This was treated with irrigation and debridement (cleaning of the wound), antibiotics, and immobilization.  Surgical pinning was not required.  His recovery was complicated by a deep venous thrombosis (DVT), a blood clot in a large, deep vein in the leg with a secondary pulmonary embolus (PE), a complication of the DVT when the thrombus breaks free [becoming an embolus] and moves to the lungs.  He was placed on an anti-coagulant (blood thinner) for 6 months for treatment and prevention of a recurrent PE.  He gradually returned to increased activity and was again running when seen in May 2006.  He reported pain in the shin (tibia) as well as the right knee with running.  X-rays showed that the fracture was healing well.  Lab work was obtained to see if there was an underlying coagulopathy (increased tendency for clotting); it was normal.  The CI did not desire to remain on active duty and he was not returned to full duty at the end of the first LIMDU period.  He was therefore referred for an MEB.  

At the 15 May 2006 MEB NARSUM examination, 4 months prior to separation, noted that the CI had been able to return to running, albeit with pain.  The CI complained of discomfort with prolonged standing and climbing stairs.  On examination, he was noted to have a fascial defect (connective tissue lining over the muscles) and tenderness over the shin.  The knee had full range of motion (ROM), but some quadriceps atrophy was present.  Crepitus (an audible or sensible grinding in the joint with movement) was also noted.  The medical officer observed that some atrophy was not unusual after an injury like this and was associated with the disuse necessary for healing.  Resolution is typically seen after resumption of normal activities.  Pitting edema was noted over the shin.  He was determined to have post-phlebitic edema (residual soft tissue swelling after the DVT).  The PE was resolved without sequelae.  

At the 12 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported persistent shin and knee pain.  On examination, tenderness and edema persisted over the shin, but strength was normal.  

At the 29 March 2007 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported that the edema had resolved.  He still had shin pain when the weather changed and some knee discomfort when climbing stairs.  He denied ankle problems.  On examination, the scar was well healed and hard to see.  There was neither edema nor atrophy.  Tenderness was not present and motion of the knee and ankle was normal.  The gait was normal.  The lungs were clear and respiration normal.  He was thought to have a resolved right tibial fracture without residuals other than the pain as described.  The post-phlebitic syndrome and PE were thought to be resolved.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the open right tibia fracture condition 10%, coded 5299-5003 (analogous to degenerative arthritis) and included patello-femoral pain syndrome (PFS) as a related Category II condition contributing to the disability.  The panel noted that the CI had a normal gait, ROM, and was able to run and concluded that the patello-femoral syndrome could not be reasonably justified as separately unfitting.  In addition, the evidence did not support a rating higher than 0% for either condition, thus no advantage would be provided to the CI even if separately unfitting.  The VA also rated the right tibial fracture residuals condition 0%, coded 5262 (impairment of the tibia and fibula), citing an absence of evidence for a malunion.  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 tibial fracture condition with associated patello-femoral pain syndrome.  

Post Phlebitic Syndrome and Category II Pulmonary Embolism.  The CI also developed a post-phlebitic syndrome and a PE secondary to the underlying DVT as discussed above.  At the time of the NARSUM examination, residual edema was still present.  This had cleared by the time of the VA C&P evaluation.  Neither examination showed persistence nor sequelae from the Category II pulmonary embolus.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the post-phlebitic syndrome condition 10%, coded 7101 (hypertension).  The VA determined that the “residuals, embolism with infarction” condition was resolved and did not service connect it.  The analogous code 7199-7114 (arteriosclerosis obliterans) was used by the VA.  The panel observed that the evidence showed that the condition was resolving prior to separation and was completely resolved shortly after separation, as expected.  No route to a rating higher than the 10% adjudicated by the PEB was found.  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 post-phlebitic syndrome condition with a related Category II PE condition.

Contended PEB Condition:  Right Hallux Valgus Deformity.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended right hallux valgus (bunion) condition was not unfitting.  The CI was noted to have asymptomatic mild hallux valgus at accession and also on the separation examination, although there was evidence that these had been symptomatic between these examinations.  The CI reported pain with boot wear at the VA C&P evaluation.  On examination, the bunions were noted to be non-tender and without redness.  Motion was normal as was the gait.  There was no performance-based evidence from the record that the bunion condition significantly interfered with satisfactory duty performance at separation.  The VA examination also noted that the CI worked as a new car salesman following separation, an activity that requires standing and walking.  He had not lost any work days due to illness.  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 open right tibia fracture and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the post-phlebitic syndrome and IAW VASRD §4.104, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right hallux valgus 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 20151012, w/attachments
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:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
							XXXXXXXXXXXXXXXXXXX
	     				Principal Deputy, Assistant 
						Secretary of the Navy
						(Manpower and Reserve Affairs)
						Performing the Duties of the 
						Assistant Secretary of the Navy
						              (Manpower and Reserve Affairs)