RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXX CASE NUMBER: PD1201532 BRANCH OF SERVICE: ARMY BOARD DATE: 20130326 SEPARATION DATE: 20021202 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard PVT/E-1 (62E/Heavy Equipment Operator), medically separated for bilateral tibial plateau stress fractures. The CI developed pain in his lower extremities between his third and fourth weeks of initial training in 2002. Despite convalescent leave, activity limitations, and physical therapy (PT), the CI failed to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “Bilateral Medial Tibial Plateau Stress Fractures,” to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were submitted by the MEB. The Physical Evaluation Board (PEB) adjudicated the“Bilateral Tibial Plateau Stress Fractures Sustained in Basic Training, unable to Complete Training” 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: “He still has or is having trouble with his legs and knees also, he has RLS; restless leg syndrome.” In block 14 (continuation of Item 5, VA Rating Information), the application states “Bipolar: suicidal/homcidle [sic]/shin splints schlerotic [sic]/ activity in his hip: R.L.S. He never filed on his feet. He caught something while in Boot Camp, his toenails most of them come completely off. If he known he had caught something in the shower he would’ve filed for it at [the] time.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in Department of Defense Instruction (DoDI) 6040.44 (Enclosure 3, paragraph 5.e.2) is limited to those conditions 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 rating for the unfitting bilateral medial tibial plateau stress fractures/shin splints is addressed below. The additional conditions listed in Block 14 of the application (knees, bipolar, suicidal, homicidal, sclerotic activity in hip, RLS, and infection of the feet) were not identified by the MEB or PEB and are therefore outside the purview of this Board. 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 Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20020916 VA (5 Mo. Post-Separation) – Effective 20021003 Condition Code Rating Condition Code Rating Exam Bilateral tibial plateau stress fractures 5099-5003 0% Patellofemoral pain syndrome right knee 5010-5260 10% 20030301 .No Additional MEB/PEB Entries. Patellofemoral pain syndrome left knee 5010-5260 10% 20030301 Combined: 0% Combined: 20% VARD 20100825 Clear and unmistakable error therefore Right Hip Synovitis increased to 10% (Combined 30%) ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which his service-incurred condition continues to burden him. 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 service and DVA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12- month interval for special consideration of 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. The PEB rated bilateral tibial plateau stress fractures under the single analogous code 5099- 5003 arthritis, degenerative (hypertrophic or osteoarthritis) code. This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44, the Board must apply only VASRD guidance to its recommendation. The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as unfitting in and of itself. Since §4.71a criteria are met for separate joint ratings for the right and left tibia plateau stress fracture in this case, the Board is pursuing separate rating and fitness evaluations as follow. Bilateral Tibial Plateau Stress Fractures Condition. The Board first considered if the bilateral tibial plateau stress fractures, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above. The CI was on a permanent profile with significant limitations that would have resulted from either condition alone. The MEB examiner documented that given the CI’s age and rapid onset of symptoms that he would not be able to return to full training status. All members agreed that the right and left tibia plateau stress fracture, as isolated conditions, would have each rendered the CI incapable of continued service within his training for his MOS and accordingly merits separate ratings. There were range-of-motion (ROM) 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. Knee ROM (In degrees) MEB ~2 Mo. Pre-Sep VA C&P ~5 Mo. Post-Sep Left Right Left Right Flexion (140 Normal) Normal ROM 140 140 Extension (0 Normal) 0 0 Comment Lower extremities: strength 5/5; sensation intact; no tenderness; ligaments stable; gait normal; pain range 0-1; “pain with activity; Hips: normal ROM; Ankles: normal ROM Mild parapatellar tenderness; strength 5/5, sensation intact; Lachman’s, anterior drawer posterior drawer neg; “pain flare-ups with activity” §4.71a Rating 10% 10% 10% 10% The right and left tibia plateau stress fractures and pain resulting from them are well documented in the service treatment record (STR). The CI underwent aggressive PT with continued pain in the bilateral tibias with any activity. A right hip X-ray revealed right basicervical femoral neck region increased sclerosis. A bone scan demonstrated bilateral medial tibial plateau stress fractures, diffuse stress change of the knees, tibia, feet, and ankles. A bilateral knee X-ray indicated stress fractures. An Orthopedic consult noted that there were bilateral stress fractures. The record contains an initial temporary L3 profile from May to August 2000 and a permanent L3 profile was issued in August 2000 for bilateral medial tibial plateau stress fractures. The MEB narrative summary (NARSUM) examination approximately 2 months prior to separation noted that although the CI’s symptoms resolved with decreased activity and he was essentially asymptomatic at the time of the examination, he would become symptomatic with any repetitive weight bearing motion such as running, marching or jumping. The examiner further opined that the CI was unlikely “to be able to return to full training status in the near future.” The NARSUM exam findings are summarized in the chart above. The CI was issued a permanent L3 profile for bilateral stress fractures with restrictions of no running, no jumping, and no marching and no repetitive load activity. The VA Compensation and Pension (C&P) examination 5 months after separation documented that activity such as stair climbing, long walks and prolonged standing caused painful flare-ups. The C&P exam findings are summarized in the chart above. X-rays document mild medial compartment joint space narrowing with very small osteophytes of the medial femoral condyle. The Board directs attention to its rating recommendation based on the above evidence. As described above the PEB bundled both conditions and rating analogous to 5003, assigned a 0% rating, based on degenerative arthritis without loss of joint space. The VA coded patellofemoral pain syndrome right knee and patellofemoral pain syndrome left knee VASRD 5010 Arthritis, due to trauma, substantiated by X-ray findings with 5260 Leg, limitation of flexion of. Disability ratings of 10% were applied to each condition, seemingly based on painful motion. Shin splints and lower extremity stress fractures are typically rated analogous to 5262 tibia and fibula, impairment of with the disability rating predicated upon slight, moderate, or marked disability. Both the MEB NARSUM and the C&P document pain with increased activity along with relatively asymptomatic periods after decreased activity as would be expected with stress fractures and stress reactions. This supports a rating of 10% for mild disability. After due deliberation in consideration of the totality of the evidence, the Board concluded that the right and left tibia stress fracture were each reasonably justified as unfitting. Considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends a disability rating of 10% coded 5299-5262 IAW VASRD §4.71a for the right tibia plateau stress fracture and 10% coded 5299-5262 IAW VASRD §4.71a for the left tibia plateau stress fracture. 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. In the matter of the bilateral tibial stress fractures condition, the Board unanimously agreed that the right tibial stress fracture and the left tibial stress fracture conditions were reasonably justified as separately unfitting. The Board, by a vote of 2:1, recommends right tibia stress fracture condition coded 5299-5262 and rated 10%, and left tibia stress fracture condition, coded 5299- 5262 and rated 10%, both IAW VASRD §4.71a. The single voter for dissent, who recommended rating each condition at 0%, voted for no recharacterization as the two 0% ratings combined would not materially change the PEB’s original rating but did not elect to submit a minority opinion. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Right Tibia Stress Fracture 5299-5262 10% Left Tibia Stress Fracture 5299-5262 10% COMBINED (w/ BLF) 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120619, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxx) WRAMC, 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxx, AR20130007439 (PD201201532) 1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)