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AF | PDBR | CY2012 | PD2012 01107
Original file (PD2012 01107.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201107
BRANCH OF SERVICE: Army  BOARD DATE: 20120716
SEPARATION DATE: 20021016


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PVT/E-1 (62J/General Construction Equipment Operator) medically separated for left leg and right foot stress fractures. He was diagnosed with stress fractures of the left distal femur and right ankle talus during basic training, and did not respond adequately to conservative treatment to continue training or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The two conditions (as the only submissions) were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The PEB adjudicated “left distal femoral stress fracture” and “stress fracture right talus” as unfitting, each rated 0%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: The application states simply, “Update status.”


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 ratings for the unfitting left leg and right foot stress fracture conditions 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 Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20020916
 VA (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Left Distal Femoral Stress Fracture 5099-5003 0% Chronic Myalgia of the Left Femur with Cortical Thickening 5255 0% 20021216
Stress Fracture Right Talus 5099-5022 0% Chronic Right Ankle Strain 5271-5024 10% 20021216
Combined: 0%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 30530 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Left Femoral Stress Fracture. The CI reported an onset of left knee pain associated with running in his 4th week of basic training. This was subsequently localized to the distal femur, and was diagnosed by imaging as a non-displaced healing stress fracture. He was treated conservatively and placed on convalescent leave, but did not improve adequately to resume basic training. Outpatient records confirm normal hip and knee exams, with normal ranges-of-motion (ROM) and gait. The narrative summary (NARSUM) noted, “he has improved over time; however, he remains moderately symptomatic at this time.” The NARSUM physical exam is excerpted below.
He has full range of motion of the knee with flexion and extension. There is no instability in the anterior, posterior, medial, or lateral planes. There are no skin changes about the left knee. His distal femur at the junction of the middle and distal thirds posteriorly is tender to palpation. There are no skin changes on the thigh. Otherwise his exam is unremarkable. There is no swelling about the left thigh. All compartments are soft.
The examiner concluded that the stress fracture "is expected to heal without incident. However, should he continue basic training he will likely have moderate to severe pain and this fracture likely would not heal." At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the examiner recorded “he can't stand on the leg all that long before he has to sit down. The leg doesn't swell, it just aches.” The VA physical exam documented a normal gait and ability “to walk on his heels, toes and outside of his feet without difficulty.” Left lower extremity physical findings were recorded as, “muscle mass and strength is normal and equal in the lower extremity. The left femur is non-tender to palpation.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB’s 0% rating analogously to 5003 (degenerative arthritis) was compliant with the criteria of that code, barring concession to either VASRD §4.59 (painful motion) or §4.40 (functional loss). The VA’s 0% rating under 5255 (femur, impairment of) was also compliant with the criteria of that code, in that the code is directed at nonunion or malunion complicating fracture; and the minimum criteria were not in evidence. Members agreed that neither §4.59 nor §4.40 was supported in defense of the minimum 10% rating under 5003 criteria. Analogous coding under 5255 with a 10% rating for slight contiguous knee impairment was also entertained; but members agreed that the rationale was too speculative, and the analogous justification too equivocal, to support that recommendation. The evidence does not support a compensable rating under any of the codes for limitation of motion at the hip or knee; and, no other available lower extremity codes are applicable to this case. 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 left femoral stress fracture condition.

Right Ankle Stress Fracture. The NARSUM noted that the CI related a history of right ankle pain “since day 1 of basic training,” although there are also entries that it occurred as a result of stepping in a hole early in training. Imaging studies revealed a stress fracture of the talus (weight-bearing ankle bone). Conservative treatment, including a cast and physical therapy, was unsuccessful. A single outpatient entry 2 months prior to separation addressed ankle ROM, documenting dorsiflexion and plantar flexion as “WNL [within normal limits]” with a modest limitation of inversion. Painful motion was not specified in this entry or addressed elsewhere in the Service outpatient record. The NARSUM did not quantify the pain but noted exacerbations with “running, jumping, marching, push-ups, sit-ups, strenuous activities, and squatting.” The NARSUM physical exam is excerpted below.
He has full range of motion with ankle plantar flexion and dorsiflexion. He has full range of motion with inversion and eversion. He has no instability in the anterior, posterior, medial, or lateral planes. He is tender to palpation about the talonavicular articulation.
The examiner concluded that the talar stress fracture "is expected to heal without incident. He is moderately symptomatic at this time. Should he continue basic training and rigorous activities he will continue to have severe pain and this fracture likely will not heal." It is not clear that goniometric measurements were performed for the NARSUM, and there is no comment regarding painful motion. The C&P evaluation proximate to separation states, “the right ankle pops, cracks and grinds. It occasionally swells up. If he is on steep ground, the ankle will roll.” The VA physical exam (normal gait as above) recorded, “the right ankle is tender anteriorly to palpation. The ankle is not swollen; there is no crepitus.” The VA ROM measurements were dorsiflexion 5 degrees (normal 20 degrees) and plantar flexion 45 degrees (normal), with painful motion specified.
The Board directs attention to its rating recommendation based on the above evidence. The PEB’s 0% rating analogously to 5022 (periostitis), which defers to 5003 criteria as with the femur condition, was compliant with VASRD §4.71a; again barring concession to §4.59 or §4.40. The VA’s 10% rating cited “painful and limited motion.” Given the absence of ankylosis or malunion, the only applicable joint code offered by §4.71a is 5271 for ankle limitation of motion which offers a 10% rating for ‘moderate’ limitation and 20% for ‘marked’ limitation. Members agreed that the VA evidence was sufficiently probative to support a rating under 5271. There is not sufficient reassurance that the ROM evidence was compliant with VASRD §4.46 (accurate measurement), and the VA evaluation was equally proximal to separation with the NARSUM and MEB evidence. Reasonable doubt therefore favors concession to the VA’s ROM evidence as a basis for the Board’s recommendation. The significant reduction in dorsiflexion could be reasonably characterized as ‘moderate’ in support of a 10% rating under 5271; and, that notwithstanding, painful motion was sufficiently established in support of a 10% rating via §4.59. After due deliberation, considering all of the evidence with deference to reasonable doubt, the Board recommends a disability rating of 10% for the right ankle condition under code 5271.


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 left femoral stress fracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the right ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5271, IAW VASRD §4.71a. 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
Left Distal Femoral Stress Fracture 5099-5003 0%
Talar Stress Fracture, Right Ankle 5271 10%
COMBINED
 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120701, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130018173 (PD201201107)
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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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