RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-00402
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060726

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Helicopter Repairer, medically separated for “bilateral compartment syndrome, lower extremities” with a disability rating of 0%.

CI CONTENTION:  The condition continues to worsen.  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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review  of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20060511	VARD - 20061108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Compartment Syndrome, Lower Extremities	5399-5311	0%	Bilateral Compartment Syndrome, Lower Extremities	5099-5021	0%	20060909	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Bilateral Lower Extremity Compartment Syndrome. The PEB combined the lower leg conditions under a single disability rating, analogously coded 5311 (muscle group XI: posterior and lateral crural muscles, and muscles of the calf) and rated 0%. 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 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.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s lower leg condition began in July 2001 as bilateral calf cramping after running and ruck marching, and in February 2002, he was diagnosed with Achilles tendinitis. On 28 May 2002, a physical therapist assessed bilateral calf pain, probably secondary to forefoot varus and altered lower extremity biomechanics. Heel eversion was noted on X-rays with resulting excess pronation of the feet bilaterally, and he was subsequently seen in podiatry and treated for forefoot imbalances with orthotic inserts. He was given temporary profiles and underwent physical therapy where he was taught stretching exercises for the lower extremities. A bone scan dated 7 September 2005 showed some mild stress reactions of the knees, ankles and a small area in the left superior calcaneus. On 21 September 2005, the CI was seen in the physical medicine clinic after experiencing bilateral lower extremity calf and leg pain during and after unit physical training runs and ruck marches. At an orthopedic consult in March 2006, he was diagnosed with exercise induced compartment syndrome based on Stryker compartment pressure testing which showed resting anterior, lateral and deep pressures at 21, 24 and 26 deep. Post-exercise results showed lower leg pain, heaviness, and numbness with anterior, lateral and deep pressures at 45, 51, and
47.  The CI deferred right side measurements and refused surgical treatment.

The 30 March 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of bilateral calf pain from the mid belly of the calves down to just above the Achilles tendon. Symptoms increased with prolonged walking, running, jumping and climbing. Physical examination incorporated findings from the 13 February 2006 MEB examination and revealed full active range of motion (ROM) of the knees, with no tenderness, instability, laxity or evidence of meniscal tears. The calves showed normal strength with no erythema, swelling or tenderness. Neurovascularly, the lower extremities were intact throughout with a negative Homan’s sign (to check for deep vein thrombosis) and brisk capillary refill. The commander’s statement dated 1 May 2006 indicated the CI’s condition consisted of calf pain, cramping, and burning associated with exertion of the muscles that prohibited him from performing basic soldering skills and duties as a helicopter repairer.

At the 9 September 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported a history of compartment syndrome, but no inflammation or need for assistive devices. The examiner right and left ankle planter flexion from 0-40 degrees (normal 0-45) and dorsiflexion from 0-20 degrees (normal), without pain. Bilateral knee ROM was from 0-140 (normal) degrees, also without pain. There was no genu recurvatum bilaterally and the calves were normal bilaterally. The examiner’s diagnosis was no compartment syndrome and he felt there were no significant effects on activities of daily living or general occupation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral compartment syndrome 0%, analogously coded 5399-5311, citing the inability to perform military specialty duties. The VA also rated the bilateral compartment syndrome 0%, but coded 5099-5021 (myositis), based on the C&P examination, citing “no significant effects” and normal calves. Panel members agreed there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled compartment syndrome was reasonably considered separately unfitting. The panel then considered its rating recommendation for each lower extremity at the time of separation. Based on the pressure elevations after exercise, the panel determined the disability was unfitting bilaterally based on interpretation of VASRD §4.56 and determination of the cardinal signs of muscle injury including “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment  of  coordination  and  uncertainty of movement.”  While  there  was no penetrating

injury to either leg, the elevated Stryker pressure measurements on the left were objectively supportive of a moderate injury warranting a 10% rating. Although the CI indicated subjective symptoms of the right leg, to speculate that the right leg measurements would be similar to the left precludes objectivity to support a moderate rating. Furthermore, there was no tenderness of the calves at either the MEB examination or the VA examination. Therefore, in the absence of pressure measurements for the right leg, a rating higher than mild at 0% could not be supported. The panel noted the VA rated the condition using code 5099-5021, however, there was no loss or motion or sufficient objective evidence of painful motion to afford a higher rating for either leg. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left lower extremity compartment syndrome, coded 5399-5311 and a disability rating of 0% for the right lower extremity compartment syndrome, coded 5399-5311.

BOARD FINDINGS: In the matter of the left lower extremity compartment syndrome, the panel recommends a disability rating of 10%, coded 5399-5311 IAW VASRD §4.56. In the matter of the right lower extremity compartment syndrome, the panel recommends a disability rating of 0%, coded 5399-5311 IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Lower Extremity Compartment Syndrome	5399-5311	10%	
Right Lower  Extremity Compartment Syndrome	5399-5311	0%	
	COMBINED	10%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170211, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190008399, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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. 
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