RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00320
BRANCH OF SERVICE:  Army	BOARD DATE:  20141209
SEPARATION DATE:  20041215

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an activated Army National Guard PV2/E-2 (21B/Combat Engineer) medically separated for stress fractures in his left leg.  This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or physical fitness standards, so he was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The stress injury, characterized as “left tibia/fibula stress fractures …,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions for PEB adjudication (see rating chart below).  The PEB adjudicated “left tibia/fibula stress fractures …” as unfitting, rated at 0%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy or AR 635-40.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Bi-lateral knee condition, back condition, and stress fractures.” 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting left leg stress fractures is addressed below.  The contended bilateral knee condition is also addressed below, but no additional conditions are within the DoDI 6040.44 defined purview of the 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.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to the VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service PEB – Dated 20041122 | VA - (~7 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Left Tibia/Fibula Stress Fractures ... | 5099-5003 | 0% | RPPS Left Knee; Stress Fracture Left Tibia and Fibula | 5257 | 10% | 20050728
Bilateral Retropatellar Pain Syndrome (RPPS) | Not Unfitting | RPPS Right Knee; Stress Fracture Right Tibia | 5257 | 10% |
No Additional MEB/PEB Entries in Scope | No Other VA Conditions in Scope
Combined:  0% | Combined:  50%
Derived from VA Rating Decision (VARD) dated 20050928

ANALYSIS SUMMARY:  Almost all analogous VASRD coding and rating determinations for the left tibia/fibula stress fractures would include consideration of knee disability and therefore, the left knee is considered with the unfitting stress fracture condition.

Left Tibia/Fibula Stress Fractures (Including Left Knee Condition).  Review of the narrative summary (NARSUM), supported by the treatment record, detailed that the CI first sought medical attention for left leg pain during basic training.  X-ray images (obtained 4 months prior to separation), showed an early left mid-tibial stress fracture.  Convalescent leave did not resolve the left leg pain and civilian bone scan documented bilateral stress fractures.  The CI developed bilateral knee pain, diagnosed as patellofemoral pain syndrome.  At the NARSUM examination (a month prior to separation), the CI had continued left leg pain.  The knee pain was resolving with some remaining stiffness.  The pain was eased by resting and aggravated by running, climbing or going down stairs.

At the NARSUM’s examiner noted the CI had a slightly antalgic gait, mild valgus (knocked-knee) of the left leg, “normal full range-of-motion” (ROM) and no laxity of the knee and ankle joints.  The left leg had diffuse tenderness along the tibia with no swelling, erythema, or ecchymosis.  Neurological exam was normal.  Pes planus was noted and the hip exam was normal.  The examiner concluded that the left tibia/fibula stress fractures did not meet retention standards while the bilateral knee condition (bilateral retropatellar pain syndrome [RPPS]) was resolving and did not fail retention standards.

At the VA Compensation and Pension exam (performed 7 months after separation), the CI reported pain in the left lower leg when he “was up” and occasional right lower leg pain.  The CI also reported bilateral knee pain, right worse than left, with occasional locking and “giving out.”  On examination, there was tenderness of both tibias, especially anteriorly on the upper third; the examiner stated that the bone felt “roughened” in this area.  The CI had normal gait with obvious bilateral genu valgus and pes planus (flat feet).  There was tenderness to palpation in both knees, “pain on motion in the right knee but not in the left knee … crepitation of movement in the right knee but not in the left.”  The CI could “extend both knees to 0 degrees, flex both from 0 to 140 degrees with no pain” (normal 0 degrees-140 degrees).  The left ankle had non-painful plantar flexion to 70 degrees (normal 45 degrees) and dorsiflexion to 15 degrees (normal 20 degrees).  Later VA exams documented worsening of left leg symptoms, with a continued 10% rating from the VA.

The physical profile listed the involved medical condition as left tibia/fibula stress fracture, without any specific mention of the knees.  Specific restrictions included no running, jumping, marching or training for the Army Physical Fitness Test.  There was no commander’s statement in evidence before the Board and it could not be located after appropriate inquiries.  It was judged by the members that the missing statement would not materially alter the Board’s recommendations.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded “Left tibia/fibula stress fractures …, chronic lower extremity pain …,” as analogous code 5099-5003, rated at 0%, stating, “Rated as analogous to degenerative arthritis without loss of joint motion.”  The Board noted that this coding is recommended by the USAPDA pain policy and that 5003 (arthritis, degenerative, hypertrophic or osteoarthritis) is a joint code and that the left knee is the referenced joint.  Any disability of the left knee would have to be subsumed under that code.  The VA rated both knees separately bilaterally at 10% using code 5257 (knee, recurrent subluxation or lateral instability), including the disability due to the tibial stress fractures in these ratings.  The VARD stated, “Given the proximity of the tibial stress fracture to your right knee and the overlapping of the pain symptoms resulting from both disabilities, we have evaluated these conditions together as a single disability.”

The Board considered the probative values of the NARSUM and VA exams.  Although the VA exam was slightly more complete with joint measurements measured in degrees and discussion of the effect of repetitive motion, the NARSUM was proximal to the date of separation (a MEB exam was obtained month prior, while the VA examination was 7 months after separation) and was determined to have greater probative value.  Any worsening of the conditions in the VA exam could be due to post-separation progression.  The ROMs in the NARSUM were deemed adequate to determine fitness for duty and disability ratings under codes 5003 and 5257.

The Board reviewed code 5262 (tibia and fibula, impairment of) as an alternate rating option, which was more specific to the unfitting condition.  The Board noted that this code subsumed knee or ankle disability in the rating criteria, similar to the VARD application of code 5257.  While both of these codes rate “Slight” disability at 10% and “Moderate” disability at 20%, the 5262 code can go to 40% for “Nonunion of, with loose motion, requiring brace” – which was not present in this case.

There was no compensable ROM impairment; and, neither the service nor VA evidence indicated the presence of ligament laxity, frequent effusions, or locking (or any indication of loose body).  There is, therefore, no VASRD §4.71a route to a rating higher than 10% under any applicable code and no grounds for additional rating of instability.  The Board determined that the CI’s ongoing pain, tenderness along the tibia, antalgic gait and extensive duty restrictions (including no running) indicated that his disability was at least “slight.”  However, the normal joint exams (without tenderness or effusion) and “normal” ROM indicated that his disability was not “Moderate.”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% under code 5099-5262 for the left leg condition (which includes the disability for the left knee).

Contended PEB Conditions.  The Board considered whether the right knee condition (RPPS) constituted a separate unfitting condition, mindful that the left knee disability was included in the rating for the left leg (see above).  The Board’s threshold for countering fitness determinations is “preponderance of evidence,” but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Examination of the right knee and leg was normal, except for the slightly antalgic gait and pes planus.  The right knee was not profiled and was not judged to fail retention standards by either the NARSUM or the MEB.  Although the profile restrictions from the unfitting left leg condition may have overshadowed any contribution from the right knee, there was insufficient performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right knee and so no additional disability rating was recommended.

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 PEB may have relied on the USAPDA pain policy or AR 635-40 for rating the left leg condition in this case, and the condition was adjudicated independently of that policy/ instruction by the Board.  In the matter of the left leg condition (including the left knee RPPS), the Board unanimously recommends a disability rating of 10%, coded 5099-5262 IAW VASRD §4.71a.  In the matter of the contended right knee condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends modifying the case determination as follows, effective the date of medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
Left Tibia/Fibula Stress Fractures ... With Left Knee RPPS | 5099-5262 | 10%
Right Knee RPPS (of Bilateral RPPS) | Not Unfitting
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140108, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20150007070 (PD201400320)

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 10% 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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-00320