RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201175 SEPARATION DATE: 20020805 BOARD DATE: 20130301 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard PV2/E-2 (12C/Basic Trainee), medically separated for bilateral tibial plateau stress fractures. The CI had bilateral knee pain since the fifth week of basic training. She was treated with physical therapy (PT), non-steroidal anti-inflammatory drugs (NSAIDs), convalescent leave for 30 days, and modification of activities. Despite treatment, she continued to have severe pain, exacerbated by running, jumping, push-ups, prolonged standing, marching, and strenuous activities. Clinical examinations, a bone scan and X-rays were consistent with non-displaced bilateral tibial plateau fractures. She did not improve adequately to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB), which determined that it was not medically acceptable. No other conditions were forwarded by the MEB to the Physical Evaluation Board (PEB). The PEB adjudicated the bilateral tibial plateau stress fractures condition as unfitting, rated 0%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated with a 0% disability rating. CI CONTENTION: “I am not able to stand for long periods of time. I experience intense pain and swelling in my legs. I have been to see doctors for treatment for my condition.” 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 IPEB – Dated 20020710 VA (>1 Mo. Post-Separation) – All Effective Date 20020806 Condition Code Rating Condition Code Rating Exam Bilateral Tibial Plateau Stress Fractures 5099-5003 0% Healed Minor Stress Fractures, Tibias, Fibulas, and Pelvic Area 5014 NSC 20020919 .No Additional MEB/PEB Entries. Combined: NSC Combined: 0% ANALYSIS SUMMARY: Bilateral Tibial Plateau Stress Fractures Condition: The CI developed bilateral knee pain during basic training which prevented continuation of training. She was treated conservatively and placed on convalescent leave for 30 days without complete resolution of symptoms. The MEB examiner, who dictated the narrative summary (NARSUM) 2 months prior to separation and was the treating orthopedist, opined that if she were to continue basic training, these fractures would not heal. She was issued a permanent L3 profile for bilateral tibial plateau stress fractures with inability to run at own pace and distance nor walk or run in pool at own pace. She was also unable to wear a 40 pound backpack or fire a rifle and unable to march or do sit- ups. There was one goniometric range-of-motion (ROM) evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Knee ROM In degrees (Normal) MEB ~2 Mos. Pre-Sep VA C&P ~1 Mo. Post-Sep Left Right Left Right Flexion (140 Normal) 135 135 Normal Normal Extension (0) 0 0 Normal Normal Comment FROM Tender proximal tibia Normal gait FROM Tender proximal tibia Normal gait Tender proximal tibia Normal gait No swelling Tender proximal tibia Normal gait No swelling §4.71a Rating 0% 0% 0% 0% The MEB NARSUM physical exam noted normal ROM with tender bilateral proximal tibial areas at the knee, normal gait, no instability, normal sensation, and normal skin. A bone scan was noted as showing bilateral stress fractures. X-rays showed healing stress fractures of the tibial plateaus bilaterally. At the VA Compensation and Pension (C&P) examination, a month after separation, the CI reported pain of both proximal tibial areas, and the left hip. The examination revealed normal knee, ankle, and hip ROM, with slight tenderness to deep palpation in the proximal tibia, no swelling, normal gait. X-rays were normal. The VA examiner diagnosed healed minor stress fractures of the tibia, fibula, and pelvic areas. The Board directs attention to its rating recommendation based on the above evidence. The Board considered VASRD diagnostic code 5099-5003 (rated analogously to degenerative arthritis) used by the PEB for a zero percent rating. The Board examined the evidence. There was no radiological evidence of arthritis and no pain on normal ROM testing to support a higher permanent disability rating. The VA determined the condition to be not service-connected (NSC) using the code 5014 (osteomalacia). The Board found no evidence in the clinical record of swelling, muscle spasm, or painful motion to support a higher rating. The Board determined the 30 day convalescence leave to be therapeutic rather than evidence of an occasional incapacitating exacerbation. The Board also considered the code 5257 (other impairment of knee) and found no evidence of recurrent subluxation or lateral instability in the clinical record for a rating under this code. Finally, it reviewed the code 5262 (impairment of tibia and fibula) and found no evidence of nonunion, loose motion, or a requirement of a brace, to support a higher rating. 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 tibial plateau stress fractures condition. 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 tibial plateau stress fractures condition and IAW VASRD §4.71a, 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 and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Bilateral Tibial Plateau Stress Fractures 5099-5003 0% COMBINED 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120615, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxx, AR20130007624 (PD201201175) 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 xxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)