RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200731 SEPARATION DATE: 20011205 BOARD DATE: 20130206 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Soldier, PFC/E-3 (88M/Motor Transport Operator), medically separated for bilateral exercise-induced compartment syndrome. The CI began having aching and intermittent tingling in his lower legs and feet shortly after induction into the Army. Despite two exercise-induced compartment release surgeries in each leg and physical therapy (PT), the CI was unable to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded exercise-induced compartment syndrome and decreased sensation and weakness lateral aspect right lower extremity (LE), status post (s/p) exercise syndrome release as medically unacceptable IAW AR 40-501 to the Physical Evaluation Board (PEB). The MEB forwarded no other conditions for PEB adjudication. The PEB adjudicated “Bilateral Exercise-Induced Compartment Syndrome with Surgical Releases without Alleviation of Symptoms” as unfitting, rated each LE at 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and he was medically separated with a combined 20% disability rating. CI CONTENTION: “I was discharged at 20% and was denied benefits until 2008. Had my initial rating been more, I may have had a better chance for coverage.” sic SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20011011 VA (12 & 13 Mos. Post-Separation) – All Effective Date 20011206 Condition Code Rating Condition Code Rating Exam Left Lower Extremity Exercise-Induced Compartment Syndrome 5399-5312 10% Exercise-Induced Compartment Syndrome, Left Lower Extremity, S/P Fasciotomy 8799-8724 0%* 20030114 Right Lower Extremity Exercise-Induced Compartment Syndrome 5399-5312 10% Exercise-Induced Compartment Syndrome, Right Lower Extremity, S/P Fasciotomy 8799-8724 0%* 20030114 .No Additional MEB/PEB Entries. Not Service-Connected x 1 20021203 Combined: 20% Combined: 0% *Increased to 10% each, and left shoulder adhesive capsulitis added, all effective 20080519 with new combined rating of 30% by VARD of 20090612. Subsequently, both were increased to 20% effective 20090821 with a new combined rating of 50%. ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application that had the gravity of his condition merited consideration for a higher separation rating that he would have had a better chance at coverage for benefits. It is a fact, however, that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. This role and authority is granted by Congress to the Department of Veterans Affairs (DVA). The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation. The Board utilizes DVA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. Bilateral Exercise-Induced Compartment Syndrome Condition. On the DA Form 199, the PEB appeared to have combined left and right exercise-induced compartment syndrome as a single unfitting condition, coded analogously to 5312, and rated 20%. However, the PEB rated each LE at 10% and the bilateral factor was applied to arrive at the combined 20% rating. There were two evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, as summarized in the chart below. Bilateral Lower Extremity MEB ~ 3 Mos. Pre-Separation VA C&P ~13 Mos. Post-Separation Left Right Left Right Anterior scar 2 fingerbreadths some decreased sensation to light touch; everter muscles 5/5 strength Some Tinel’s (lightly tapping over the nerve elicits a tingling sensation-nerve irritation) throughout scar; some weakness of everter muscles 4/5 strength Motor: strength, muscle tone of major muscle groups normal; normal gait; Sensory: pain, touch, proprioception intact; patellar/Achilles tendon reflexes 2+ symmetrical; plantar responses flexor bilaterally (normal) Stable to valgus/varus stresses, negative Lachman’s; no pivot; no effusion; well healed scars 15 cm long; tender to palpation (TTP); calf size 40 cm; symmetric; reflexes symmetric; normal sensation to light touch on dorsum lateral aspect and plantar aspect feet; heel-toe walk intact; good strength with plantar flexion/extensor hallicus longus §4.71a Rating 10% 10% 10% 10% The CI had the following four surgeries: 1. 20000113 Right Leg Exercise-Induced Compartment Release 2. 20000310 Left Leg Exercise-Induced Compartment Release 3. 20001206 Repeat Right Leg Exercise-Induced Compartment Release 4. 20010108 Repeat Left Leg Exercise-Induced Compartment Release The CI was granted an L3 Profile in July 2001 for bilateral exercise-induced compartment syndrome with restrictions of no running, no jumping, no climbing, no crawling, and no marching. The MEB narrative summary (NARSUM), completed approximately 3 months prior to separation, indicated that the CI had pain in his bilateral lower extremities with running and prolonged standing; numbness and weakness most notably on the right LE that interfered with activities of daily living; episodes of legs that fell asleep after standing at attention or parade rests after five minutes timeframe; and running limited to one quarter of a mile because the right leg more often than the left leg would fall asleep and slap the pavement. The NARSUM physical exam findings are summarized in the chart above. The VA Compensation and Pension (C&P) examination, completed approximately 13 months after separation, indicated that the CI continued to have pain and patchy tingling in both lower extremities that was made worse with exercise, prolonged walking and running. The C&P physical exam findings are summarized in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the bilateral exercise-induced compartment syndromes 5399 analogous to 5312 Group XII muscle group and assigned a 10% rating for each leg. The VA individually rated left and right LE exercise-induced compartment syndrome, s/p fasciotomy analogously to 8724 neuralgia and initially rated as 0% for each lower extremity. After a reevaluation examination in January 2009, the VA increased the rating to 10% for each LE. These ratings were subsequently increased to 20% each after another repeat examination in October 2009. Throughout the orthopedic service treatment record (STR) notes, there was documentation of numbness on the bottom of the left foot and a positive Tinel’s sign on the right LE. Both the NARSUM and C&P examiners documented symptoms of numbness and weakness in both legs, legs falling asleep after standing at parade rest after 5 minutes, and pain with patchy tingling in both LEs. The PEB DA Form 199 specifically noted the right leg had” decreased sensation and weakness in the lateral aspect” and “there is no muscle atrophy.” The Board reviewed the tenants of §4.124 Neuralgia -characterized usually by a dull and intermittent pain, of typical distribution to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. The Board considered that the coding of 5399-5312 does not support a rating higher than 10% and determined that the VA rating schema that focused on neuralgia symptoms better reflected the functional impairment due to the bilateral exercise– induced compartment syndrome condition. However, this coding scheme still results in a disability rating of 10% for each LE at the time of separation from service and offers no advantage to the CI. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral exercise-induced compartment syndrome. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the bilateral exercise-induced compartment syndrome condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability rating and separation determination: UNFITTING CONDITION VASRD CODE RATING Left Lower Extremity Exercise-Induced Compartment Syndrome 5399-5312 10% Right Lower Extremity Exercise-Induced Compartment Syndrome 5399-5312 10% COMBINED (w/ BLF 1.9) 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120607, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxx, AR20130006185 (PD201200731) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)