RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-03791
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20081031

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “proximal tibia stress fractures, bilateral” with a disability rating of 20%.

CI CONTENTION: His condition made him miss work and time with family. He states his compensation should be increased. He also contends that the VA diagnosed him with sleep apnea.  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 - 20081009	VARD - 20090722	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Proximal Tibia Stress Fractures, (Right 10% and Left 10%)	5299-5262	20%	Bilateral Knee Strain	5099-5010	20%	20080408	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Bilateral Proximal Tibia Stress Fractures. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral knee condition started on about the third day of basic training  when he reported at  an emergency room visit that he twisted his left knee on   18 April 2008. X-rays of both knees on 23 April 2008, ordered for left knee pain after twisting and right knee pain without trauma, were normal bilaterally. Weight-bearing X-rays of the knees were  again  normal  on  5  May  2008. However,  an  MRI  of  the  right  knee  on  16  May  2008

demonstrated a possible transverse fracture line versus visibility of the residual physeal (growth plate) scar at the proximal medial metadiaphysis. There were post traumatic changes including severe tearing of the medial collateral ligament (MCL) and medial retinaculum with a small retropatellar effusion. An MRI of the left knee showed severe tearing of the MCL and medial retinaculum with a retropatellar effusion and post traumatic bony edema. A small transverse fracture of the proximal medial metadiaphysis (area of bone around the former growth plate) versus a residual physeal scar could not be excluded. Knee X-rays dated 19 May 2008 showed subtle increased densities in the proximal left tibia, which may have represented an occult stress fracture.

At an orthopedic clinic visit dated 28 May 2008, examination of both knees had a range of motion (ROM) past 90 degrees, but became mildly painful on the medial side past that point. Both knees appeared ligamentously stable and both were tender on the medial side. He was treated with a walker, wheelchair, and convalescent leave. When he returned from convalescent leave, he was still having pain and a second convalescent leave of 30 days was ordered. A second MRI revealed healing stress fractures, however, there was still edema present in the medial aspect of both proximal tibias.  Because of persistent pain with low impact activities, an MEB was initiated.

At the 8 April 2008 VA Compensation and Pension (C&P) examination, 5 months before separation, the CI reported bilateral knee pain with stiffness, swelling, and giving-way. His pain was reported to be 7/10, which occurred two to three times per day and was exacerbated by prolonged standing and sitting. Physical examination revealed a normal gait. The range of motion (ROM) for flexion of left knee was from 0 to 125 degrees (normal 140) and flexion of the right knee was 0-125 degrees, with pain beginning at 125 degrees bilaterally. There was no laxity, instability, or evidence of a meniscal tear of either knee. There was no edema, effusion, instability, weakness, abnormal movement, or guarding of movement. X-rays of the knees did not show any degenerative changes or evidence of fractures.

The 10 September 2008 MEB NARSUM examination, one month prior to separation, noted the complaint of bilateral knee pain. Physical examination revealed the right knee ROM for flexion was 0-120 degrees, with pain at 120 degrees. Extension was 0-5 degrees of hyperextension with no pain. The left knee ROM was to 120 degrees with mild pain medially at the maximum, but no fatigue was noted. He had no varus or valgus laxity and a 1A Lachman examination (no instability). He had a negative posterior drawer and no increased external rotation at 30 or 90 degrees. There was no noted lateral joint line tenderness and only mild medial joint line tenderness, which was more diffuse than just on the joint line. Bilateral X-rays dated 3 June 2009, 7 months after separation, showed no abnormalities.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral knee condition 20% (10% for the right knee and 10% for the left knee), analogously coded 5299-5262 (tibia and fibula, impairment), citing slight disability of the right and left knees. The VA also initially rated the bilateral knee condition 20%, analogously coded 5099-5010 (arthritis, due to trauma, substantiated by X-ray findings) based on the C&P examination, citing X-ray evidence revealed involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. In a follow-up rating the VA rated the left knee strain 10%, coded 5099-5024 (tenosynovitis) and the right knee strain 10%, coded 5099-5024, based on the VA examination, citing pain or limited motion of a major joint or group of minor joints for the left knee and for the right knee.

There was no evidence of moderate or marked knee disability of either knee to support a 20% or 30% rating under the 5262 code (tibia and fibula, impairment). There was no limitation of motion of flexion or extension (5260, 5261), and no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under those respective codes. 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 bilateral proximal tibia stress fractures.

BOARD FINDINGS:  In the matter of the bilateral proximal tibia stress fractures and IAW   VASRD
§4.71a, 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:

	PD-2017-03791

AR20190012171, XXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXX

	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.

	PD-2017-03791