RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03193
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080318

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Human Resource Specialist, medically separated for “impairment of right tibia” and “post phlebitis syndrome,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20080303	VARD - 20081128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Impairment of Right Tibia	5262	10%	Right Tibia Fracture, with Residual Right Knee Pain	5262	10%	20080912	
Post Phlebitis Syndrome	7121	0%	Post Phlebitis Syndrome	7121	0%	20080912	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Impairment of Right Tibia.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right tibia condition began in March 2007 after tripping during basic training.  On 20 March 2007 X-rays showed a right comminuted tibial diaphyseal (midsection) fracture.  Treatment consisted of crutches, a splint, and a profile.  At the orthopedic clinic she had a long cast placed on the right lower extremity.  On 28 March 2007 the fracture was in good alignment, but on 3 April the cast was changed due to its breakdown from having gotten wet in the shower.  While on convalescent leave, the CI noticed marked swelling of her right leg and toes and discoloration of the toes.  She was seen in the ER on 16 April 2007 with the complaint of increasing right leg pain, and was evaluated with a D-dimer study (to determine a clot in a vein) which was equivocal.  The cast was then bivalved and she was treated with Lovenox (enoxaparin, a parenteral anticoagulant).  A venous duplex ultrasound revealed a deep vein thrombosis (DVT) at the calf level and gastrocnemius vein. She was treated with heparin, followed by Coumadin (warfarin, an anticoagulant) orally.  

On 20 April 2007 the CI underwent a closed reduction of the right tibia under general anesthesia based on X-rays dated 16 April 2007 that showed a comminuted fracture with mild angulation at the junction of the middle and distal one-third of the right tibia.  Post procedure X-rays showed reduction of the right tibia fracture with anatomic alignment.  She then had right heel pain and the cast was cut, but not removed.  A follow-up right lower extremity venous duplex ultrasound on 26 April 2007 was positive for a DVT of the isolated gastrocnemius vein with no evidence of extension.  The CI’s right leg fracture failed to heal with casting, and she underwent an open reduction-internal fixation with intramedullary tibial nailing on 27 April 2007.  She had postoperative physical therapy and showed improvement in ambulation with the use of crutches and a fracture boot.  The CI’s last physical therapy session was on 25 September 2007 when she had 4/5 strength in her right quadriceps with good control.  Interlocking screws were removed on 17 October 2007 under general anesthesia.  X-rays on 23 October 2007 showed good healing of the tibial fracture.  The orthopedic surgeon on 30 October 2007 recommended continued protective weight bearing with crutches or a fracture boot, while on 29 November 2007 he felt she was not maximally medically improved and did not believe she was fit for military duty. 

During the 24 January 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported a tibia fracture and knee pain from surgery.  Physical examination revealed right lower leg weakness and quadriceps atrophy.  On 28 January 2008 the physical therapy average active range of motion (ROM) measurement of the right knee was -5 degrees to 138 degrees (normal 0-140).  There was no limitation secondary to pain or muscle guarding, although minimal pain was present at the end of passive right knee extension, and there was a 2+ Lachman’s test (to determine laxity) of the right knee.  

The 11 February 2008 MEB NARSUM examination, 1 month prior to separation, noted complaints of a history of a right tibial fracture with pain of approximately 7/10, which increased with activity and ascending steps.  Physical examination showed a well-healed incisional scar of the right leg.  The knee and the medial leg showed only minimal tenderness, no edema, no stasis dermatitis, and no other skin changes.  She had full active ROMs of the right knee joint and the right ankle joint.  There was no swelling, erythema, or signs of infection around the surgical sites, and no trophic changes or signs of any type of nerve damage associated with the right lower extremity.  Her gait was normal as was the right knee, with strong collateral ligaments and a very slight anterior drawer with a definitive endpoint.  No crepitus (grinding) was present.  

At the 12 September 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported significant, constant right knee pain with a severity of 7/10. She also reported locking, the sensation of giving way, and popping in the knee.  The examiner found some tenderness on the lower third of the right leg.   There was no swelling.  Numbness was present at the site of the operative scar.  The anterior drawer (laxity) sign was positive and there was tenderness with McMurray’s test (to determine a meniscal tear), but no tenderness with varus or valgus strain.  Right knee flexion was 150 degrees (normal 140) and extension was 0 degrees (normal).  There was crepitation (grinding sensation) with the ROM.  X-rays showed post-surgical changes in the right tibia with a healed distal tibial diaphyseal fracture and no evidence of hardware failure or acute osseous abnormality.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the impairment of the right tibia condition 10%, coded 5262 (tibia and fibula; impairment of), citing VASRD §4.21 and noting similar impairment of function as required for a 10% rating using code 5262 despite lack of nonunion or malunion.  The VA also rated the right tibia fracture with residual knee pain condition 10%, coded 5262, based on the C&P examination, citing evidence of right knee impairment as a residual of the right tibial fracture and its subsequent medical management.

Panel members noted the CI sustained a fracture of the right tibia that was surgically repaired with an intramedullary rod.  While x-rays showed healing of the tibia fracture prior to separation, it was not until the VA examination after separation that X-rays showed complete healing.  Therefore, use of an analogous code 5262 would be applicable for rating purposes.  At the NARSUM examination both the knee and ankle ROMs were normal, but there was slight laxity of the knee.  Therefore, the panel is in accord with the PEB and VA ratings of 10%.  Neither the knee or ankle disability was consistent with a moderate disability; therefore, a 20% rating is not warranted.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the impairment of right tibia condition.  

Post Phlebitis Syndrome.  According to the STR and MEB NARSUM, the CI’s post phlebitis syndrome began after her right leg cast was changed in April 2007.   As noted previously, she was seen in the ER on 16 April 2007 with the complaint of increasing right leg pain, was evaluated with a D-dimer study, the cast was bivalved, and she was treated with Lovenox.   A DVT was identified and treated with heparin, followed by Coumadin.  Prior to her 27 April 2007 surgery she was switched to heparin, and after surgery she resumed and remained on Coumadin.  

During the MEB examination the CI reported having had a DVT and was taking Coumadin.  No physical findings were reported.  The MEB NARSUM examination noted the complaint of a DVT.  The INR, which is used to follow blood clotting while on anticoagulation medication, was 6.7 (normal 2.0-3.0).  Physical examination showed the knee and the medial leg were only minimally tender without edema, stasis dermatitis, or other skin or trophic changes.  At the C&P examination the CI reported a history of a post-phlebitic syndrome with pain in the right leg, and she no longer took Coumadin.  Physical examination showed some tenderness on the lower third of the right leg without any swelling.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the post phlebitis condition 0%, coded 7121 (post-phlebitic syndrome of any etiology), citing “asymptomatic but presently requiring Coumadin.”  The VA also rated the post phlebitis condition 0%, coded 7121, based on the C&P examination, citing a higher rating “is not warranted unless there is intermittent edema of the extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery, which was not noted at the time of your examination.”  Members noted that proximate to separation the CI had only minimal tenderness, although was still taking Coumadin.  However, at the time of the post-separation VA C&P examination she still had some tenderness but was no longer taking the Coumadin.  Therefore, a 10% rating, which requires “intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery” is not a viable option.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the post phlebitis syndrome.  

BOARD FINDINGS:  In the matter of the right tibia condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the post phlebitis syndrome and IAW VASRD §4.104, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20170412, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180012245, 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,					      

Enclosure