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AF | PDBR | CY2012 | PD2012 01179
Original file (PD2012 01179.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xx         CASE Number: PD1201179
BRANCH OF SERVICE: NAVY  BOARD DATE: 20130502
SEPARATION DATE: 20030317


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Seaman Recruit (SR)/E-1 (MOS/Seaman Recruit) medically separated for bilateral tibial stress fractures. In October 2002 (within 2 months of entering Boot Camp), the CI developed bilateral knee/leg pain after running during physical training. There was no specific injury noted. Radiographic imaging revealed multiple bilateral stress fractures of the legs, shin splints of the left tibia and stress reactions in both ankles. She was treated with rest, non-steroidal anti-inflammatory drugs (NSAIDS) and vitamin supplementation. Initially, she responded to treatment (both legs pain free in December 2002); however, in January 2003 (still in Basic Training), she developed a new left tibial stress fracture, could not satisfy physical training requirements and was referred for a Medical Evaluation Board (MEB). The MEB characterized the knee condition as bilateral medial tibial plateau stress fractures and forwarded it for Physical Evaluation Board (PEB) adjudication IAW SECNAVINST 1850.4E. The MEB also identified and forwarded four other conditions, identified in the ratings comparison chart below, for PEB adjudication. The Informal PEB (IPEB) adjudicated bilateral medial tibial plateau stress fractures as unfitting, rated 10% and 0%, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be either Category II (conditions that contribute to the unfitting condition) or Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition) as summarized in the rating comparison chart below. The CI made no appeals, and was medically separated with a 10 % combined disability rating.


CI CONTENTION: The CI elaborated no specific contention in her application.


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 bilateral medial tibial plateaus stress fractures 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 Naval Records.


RATING COMPARISON :

Service IPEB – Dated 20030221
 VA - ( 2 weeks Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Medial Tibial Plateau Stress Fracture R-5003-5262
L-5003-5262		 10% 0% Stress Fracture, Lt. Medial Tibial Plateau and Femoral Condyle 5262 20%* 20030303
Bilateral Medial Femoral Condyles Stress Fracture CAT III Stress Fracture, Right. Medial Tibial Plateau and Femoral Condyle 5262 20%* 20030303
Stress Fracture, Right. Mid-Tibia CAT II Stress Fracture, Right Mid Tibia 5262 NSC 20030303
Shin Splints, Left Tibia CAT II Shin Splints, Left Tibia 5262 NSC 20030303
Bilateral Ankle Stress Reaction CAT III Bilateral Ankle Stress Reactions 5271 NSC 20030303
No Additional MEB/PEB Entries
 Other x12 20030227
Combined: 10%
 Combined: 40%*
Derived from VA Rating Decision (VA RD ) dated 200 30521 (most proximate to date of separation [ DOS ] )
* Ratings and combined rating reduced to 0% effective 20040801 by VARD dated 20050216
Note: In the above chart: “R” indicate Right and “L” indicate Left.

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed by the CI regarding the impairment with which his conditions continue to burden him, and the significant impact they have had on his quality of life. It is noted for the record that the Board is subject to the same laws for disability entitlements as those under which the Disability Evaluation System (DES) operates. The DES has neither the role nor the authority to compensate members for future severity or potential complications of conditions. That role and authority is granted to the Department of Veterans' Affairs (DVA). The Board evaluates DVA evidence in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness and rating determinations at the time of separation. While the DES considers all of the CI's medical conditions, compensation can only be offered for those conditions that cut short a member’s career, and then only to the degree of severity present at the time of separation. The DVA, however, is empowered to compensate for service-connected conditions and to periodically re-evaluate conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment change over time.

Bilateral Medial Tibial Plateaus Stress Fractures Condition). The CI developed bilateral leg pain within 2 months of beginning Basic Training. In October 2002, she reported right shin pain during physical training. Initial treatment and evaluation was with rest, ice, NSAIDS and a bone scan 3 days later that revealed stress fractures involving both medial tibial plateaus and medial femoral condyles, along with her right mid-tibia. Over the next 2 months, treatment with rest, physical therapy (PT), NSAIDS and vitamin supplementation resulted in her becoming asymptomatic. As she began increasing her physical activity, she developed a new left tibial stress fracture and was referred into the DES. The narrative summary (NARSUM) prepared 2 months prior to separation noted “pain with ambulation, and progressively increasing pain with running. No history of trauma. She reported no previous knee or lower extremity pain prior to entering boot camp.” Physical exam of both knees revealed a normal gait; no swelling, effusion or quadriceps inhibition; no tenderness to palpation of patella, patellar tendon or pre-patellar bursa; no instability to exam and no evidence of meniscal injury. Examination of both tibia revealed positive tenderness at medial femoral condyle & medial tibial plateaus; no edema or ecchymosis. Radiographic studies revealed the following findings: bilateral tibia X-rays obtained on 2 December 2002 revealed bilateral mid diaphyseal tibial stress fractures and bilateral knee X-rays on 16 January 2003 were negative. At the VA Compensation and Pension (C&P) exam performed 2 weeks prior to separation, the CI reported a similar history to the one given above. Physical exam revealed positive tenderness medial tibial plateaus and medial femoral condyles; no local tenderness or swelling, no painful movement or weakness; no effusion, synovial thickening or crepitus; no evidence of instability or cartilage pathology and no leg muscle atrophy. There was marked knock-knee deformity and positive moderate lack of endurance but no lack of coordination.

The Board directs attention to its rating recommendation based on the above evidence. The PEB applied the analogous VASRD code of 5003-5262 (impairment of tibia and fibula) to each leg separately. The IPEB document rates one leg 10% and the other 0% without differentiation. The handwritten Joint Disability Evaluation Tracking System document contains an entry indicating the right leg was to be rated at 10% with the left leg rated at 0%. The additional MEB conditions were adjudicated as either contributing or not unfitting conditions. Members agree that each leg was adjudicated as separately unfitting by the PEB and the tibial stress fractures, medial femoral condyle stress fractures and the shin splints were associated with the same disability and fitness implications. An attempt to provide separate tibial and femoral condyle ratings would be confounded by VASRD §4.14 (avoidance of pyramiding). Analogous ratings IAW VASRD §4.20 (analogous rating) is permitted when “the anatomical localization and symptomatology are closely analogous.” With the same findings as the PEB, the VA also applied VASRD code 5262 to each individual leg; however, they rated each leg 20% (moderate disability) based on the examiner’s report of “moderate lack of endurance” in each knee. VASRD code 5262 is undoubtedly the best clinical fit for rating the CI’s condition with the ratings based on slight, moderate or severe disability. The evidence documents that the CI had 4 weeks of bilateral leg pain which became asymptomatic with one week of rest; only to have her symptoms return within a week of increased activity. This clinical course, quickly becoming asymptomatic with decreased activity, is most consistent with a slight, 10%, disability as opposed to a moderate, 20%, disability. It is very likely, although speculative, that by the time of separation (2 weeks after the C&P exam) the CI was again asymptomatic in respect to her bilateral leg pain. It is noteworthy that the VA’s rating was modified to a 0% evaluation for each leg effective 17 months after separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right tibia/knee pain and 10% for the left tibia/knee pain conditions.


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 right tibial stress fractures condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a. In the matter of the left tibial stress fractures condition, the Board, by a two to one vote, recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a. The single vote of dissent recommended a 0% rating for the left tibial stress fracture condition and elected not 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 her prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Tibial Periostitis / Stress Fracture Right Leg 5299-5262 10%
Tibial Periostitis / Stress Fracture Left Leg 5299-5262 10%
COMBINED (w/ BLF)
 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120614, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         xx
         Director of Operations
         Physical Disability Board of Review


 MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
                  COMMANDER, NAVY PERSONNEL COMMAND
                                         
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) PDBR ltr dtd 28 May 13 ICO x
(c) PDBR ltr dtd 22 May 13 ICO x
(d) PDBR ltr dtd 22 May 13 ICO x
(e) PDBR ltr dtd 17 May 13 ICO x
(f) PDBR ltr dtd 10 May 13 ICO x
(g) PDBR ltr dtd 17 May 13 ICO x

1. Pursuant to reference (a), I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (g).
         
2. The official records of the following individuals are to be corrected to reflect the stated disposition:

a. former USN : Disability separation with a final disability rating of 20% (increased from 10%) effective 1 March 2003.

b. former USN : Disability separation with a final disability rating of 20% (increased from 10%) effective 15 September 2002.

c. former USMC : Disability retirement with a final disability rating of 40% (increased from 20%) and placement on the Permanent Disability Retired List effective 14 January 2004.

d. former USN : Disability retirement with a final disability rating of 30% (increased from 20%) and placement on the Permanent Disability Retired List effective 15 November 2002.

e. former USMC : Disability retirement with a final disability rating of 30% (increased from 20%) and placement on the Permanent Disability Retired List effective 31 August 2005.

f. former USMC : Disability separation with a final disability rating of 20% (increased from 10%) effective 15 November 2001.

3. Please ensure all necessary actions are taken, included the recoupment of disability severance pay if warranted, to implement these decisions and that subject members are notified once those actions are completed.



                                                      xx
                                                      Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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