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AF | PDBR | CY2012 | PD2012 00695
Original file (PD2012 00695.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xx         CASE: PD1200695
BRANCH OF SERVICE: NAVY  BOARD DATE: 20130613
SEPARATION DATE: 20011016


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SR (Basic Recruit) medically separated for multiple stress reactions/healing stress fractures. The CI initially presented in August 2001 for bilateral leg pain. A bone scan revealed multiple stress fractures. Prognosis for future military service was determined to be poor and she was referred for a Medical Evaluation Board (MEB). The bilateral leg condition(s), characterized as “right femoral shaft stress fracture, DNEPTE, bilateral medial tibial plateau stress fracture, DNEPTE and left cuboid stress fracture, DNEPTE” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The PEB adjudicated “multiple stress reactions/healing stress fractures” as unfitting rated 20%, with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions , left cuboid stress fracture, bilateral medial tibial plateau stress fracture and right femoral shaft stress fracture, were determined to be C ategory II ( c ontribut ing to u nfit condition ) . The CI made no appeals, and was medically separated .


CI CONTENTION: “I feel that my injuries were quite servere and I had more complications than what they based my ratings on. I now suffer with arthritis and muscle aches and spasms, along with hip pain swellin soreness.”


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 multiple stress fractures are addressed below; and, 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 Naval Records.


RATING COMPARISON:


Service IPEB – Dated 20011002
 VA - (10dys Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Multiple Stress Reactions/Healing Stress Fractures
 5022-5003 20% Stress Reactions, Left Lower Extremity (Left Femur, left ... Medial Tibial Plateau and Left Ankle and Foot 5299-5262 10% 20011010
Stress Reactions, Right Lower Extremity (Right Femur, Right ... Medial Tibial Plateau And Right Ankle and Foot 5299-5262 10% 20011010
No Additional MEB/PEB Entries
 Other x 4 20011010
Combined: 20%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200111 9 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment and worsening severity with which her service-incurred condition continues to burden her. It is a fact, however, that the Disability Evaluation System 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 Veterans’ Affairs.

Multiple Stress Reactions/Healing Stress Fractures Condition. The narrative summary (NARSUM), 6 September 2001 noted the CI was initially evaluated for non-trauma related hip and bilateral leg pain in August 2001. Physician examination noted antalgic gait. Examination of the hips recorded full flexion, no pain on internal rotation, and no tenderness to palpation. Lower extremity examination revealed tenderness, no evidence of inflammation, or joint instability. The right quadriceps appeared slightly fuller than the left. Range-of-motion (ROM) for bilateral knees and ankles were recorded as full. Edema was noted in the dorsum of the left foot; the examiner diagnosed overuse syndrome. Radiographs of the left foot (8 Aug 2001) showed no evidence of fracture or dislocation. X-rays of the left tibia and fibula (14 Aug 2001) were suspicious for stress fracture of the medial tibial plateau. The CI underwent multiple series of radiographs and bone scans of the lower extremities. There was no evidence of fracture, dislocation, bone destruction or soft tissue abnormality in any of the studies. Bone scan on 22 August 2001 demonstrated healing stress fracture in the mid shaft of the right femur, bilateral stress induced reaction medial compartment of the knees, possible stress fracture on the left medial tibial condyle, and benign bone lesion, aseptic necrosis and/or stress fracture in the area of the left cuboid bone-(later determined to be a stress fracture and not aseptic necrosis). A CT scan performed in August 2001, to evaluate bone mineral density, demonstrated normal bone mineralization and no evidence of osteopenia or osteoporosis. The CI continued to have pain with prolonged standing, running, and marching despite medication. On 6 September 2001, the CI was diagnosed with right femoral shaft stress fracture, bilateral medial tibial metaphysis stress fractures, and left cuboid stress fracture. The examiner noted poor pain control and indicated the CI’s pain description was vague in quality, quantity and location. Treatment records indicated no objective findings of knee locking, knee or ankle instability, effusions, or limitation in ROM. No profiles were noted in the service treatment records (STRs). The MEB NARSUM dictated approximately a month prior to separation, recorded a brief history of the bilateral lower extremity pain. On physical examination gait was recorded as antalgic and there was tenderness over the mid-right thigh without edema. Weight and height were recorded at 107 pounds and 60 inches. The right femur examination suggested stress fracture (positive fulcrum and Patrick’s test). The examiner opined healing of the stress fractures would require an additional 6 to 12 months and the CI could not perform her military duties in a full duty capacity. At the VA Compensation and Pension examination on 10 October 2001, 6 days after separation, physical examination of the feet recorded diffuse tenderness without swelling with full ROM of ankle and digit joints and no significant pain or weakness. There was tenderness over the mid-tibial areas without evidence of inflammation. There was tenderness on the mid-portion of both knees and no evidence of inflammation. The ankles ROM recorded dorsiflexion of 30 degrees and plantarflexion of 45 degrees with normal strength and no pain. Calf measurements were equal bilaterally. There was no evidence of ankle instability. Knee ROM recorded bilaterally at 150 degrees without pain or weakness. There was no evidence of knee inflammation, crepitus, or instability and no evidence of lack of endurance or lack of coordination noted. Mild deep tenderness over the right femur was elicited, but there was no increased pain with any rotation or flexion of the femur, and no evidence of inflammation.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the multiple stress reactions/healing stress fracture condition as a single unfitting condition at 20% under the analogous code 5022-5003 (periostitis/degenerative arthritis included in the preponderance of evidence). The VA separated the lower extremities and rated each 10% for stress reactions, slight lower extremity disability, coded analogously 5299-5262. Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that the preponderance of evidence demonstrates that each condition incorporated in the overall combined rating can be justified as separately unfitting in order to remain eligible for service rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (Higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. The STR evidenced bilateral lower extremity involvement. There were radiographic findings of stress fractures bilateral lower extremities. Evidence showed that each lower extremity was equally contributory to the CI’s functional impairment. The Board determined that the preponderance of evidence demonstrated that the left and right lower extremity conditions were separately unfitting. The CI’s primary functional impairment was bilateral lower extremity pain without evidence of instability, meniscal injury, or other limitation of motion. IAW VASRD §4.59, (Painful motion), each lower extremity would be rated at 10% for a combined rating of 20%. Since this would not confer a higher rating than the PEB adjudication, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the multiple stress reactions/healing stress fractures conditions.

The Board then considered the Category II left cuboid stress fracture, bilateral medial tibial plateau stress fracture, and the right femoral shaft stress fracture conditions. The Board opined that the Category II conditions were integral components of the multiple stress reactions/healing stress fractures pathology as manifested by bilateral lower extremity pain and IAW VASRD §4.14 (Avoidance of pyramiding) could not be recommended for separate ratings. The Board was unable to find any additional route to a higher disability rating. Whereupon, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB’s Category II adjudication of the multiple stress reactions/healing stress fractures condition(s).


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 multiple stress reactions/healing 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
Multiple Stress Reactions/Healing Stress Fractures
 5022-5003 20%
COMBINED
 20%




The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120606, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





xx
President
Physical Disability Board of Review


 MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) CORB ltr dtd 19 Aug 13

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their respective forwarding memorandum, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:
- former USMC
- former USN
- former USMC
- former USN
- former USMC
- former USN
- former USN
- former USMC
- former USN


                                                      xx
                                                     Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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