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AF | PDBR | CY2012 | PD2012 01359
Original file (PD2012 01359.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD 12-01359      
BRANCH OF SERVICE: Army          BOARD DATE: 20130829
SEPARATION DATE: 20030129                


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (31U, Signal Support System Specialist) medically separated for a bilateral lower extremity condition. He began experiencing bilateral leg pain with strenuous activity early in service which worsened over time, and was subsequently diagnosed as exertional compartment syndrome. Surgical intervention was deferred, and the symptoms did not respond adequately to conservative treatment to meet the requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as “bilateral exertional compartment syndrome”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The informal PEB adjudicated the bilateral condition as unfitting, rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated with that Service disability rating.


CI CONTENTION: “I was once a very physical person, but due to the disability I'm limited on the amount of Cardiovascular exercise I'm able to conduct, and I've had difficulty maintaining a healthy weight. I also have loss of mobility to my shoulder, and suffer from nightmares, mood swings and drinking problems from PTSD.” [sic]


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 Service rating for the unfitting bilateral leg condition(s) is addressed below. The referenced shoulder and psychiatric conditions were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. Those, and any other conditions or contention not requested in this application, remain eligible for future consideration by the Service Board for Correction of Military Records.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him but must emphasize that the Military Disability Evaluation System (MDES) has neither the role nor the authority to compensate service members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veteran Affairs, operating under a different set of laws.



RATING COMPARISON :

Service PEB – Dated 20021213
 VA - 1 Mo. Post-Separation
Condition
 Code Rating Condition Code Rating Exam
Exertional Compartment Syndrome [ECS], Bilateral Lower Extremities 5099-5003 0% ECS, Left Leg 5299-5262 10% 20030312
ECS, Right Leg 5299-5262 10%
No Additional MEB/PEB Entries
 Other x 1
Combined: 0%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 30425 .


ANALYSIS SUMMARY:

Bilateral Exertional Compartment Syndrome. The CI reported bilateral lower leg pain with exercise dating to basic training, although the earliest entry in the Service treatment record (STR) for the complaint was January 2000; and, the condition was first profiled in October 2002 (4 months pre-separation). The initial diagnosis was shin splints; but, after further evaluation, an orthopedic consultant in July 2002 made the diagnosis of exertional compartment syndrome (anterior tibial). Surgical decompression was offered as an option, but the CI elected conservative management with the attendant expectation of permanent profile and MEB. Various STR entries documented normal gait, normal lower extremity joint exams with full range of motion (ROM), and normal strength testing. The narrative summary (NARSUM) documented:
He describes paresthesias and numbness radiating from the knees downward with running and with other activities. It resolves with rest and ice after approximately ten minutes. He does note that at times the pain and numbness can progress to the point that he is unable to continue with his activities.
The only relevant positive finding on the NARSUM physical exam was, “tenderness to palpation bilateral anterior tibial aspects.” At the VA Compensation and Pension (C&P) exam (1 month post-separation), the examiner recorded “ever more severe throbbing pains in his anteromedial tibial area after running, riding a bicycle, and doing heavy physical exertion”; noting resolution within 5-20 minutes of cessation. The VA physical exam documented, “There is no tenderness, swelling, increased heat, or any other obvious signs on examination of this man's lower legs. He describes the location of the pain after running as being along the anteromedial tibial surface and just posterior.” A VA neurologist on the same day documented normal lower extremity strength, reflexes, and sensory findings; concurring with the diagnosis of exertional compartment syndrome as the etiology of the condition.

The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the separate leg conditions under a single rating coded analogously to 5003 (degenerative arthritis). The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral extremity adjudications; although, separate fitness assessments must justify each Service disability rating. The STR, NARSUM, commander’s statement, profile, and MEB submission all address a bilateral diagnosis and limitations, with no left/right distinction. It is speculative to conclude that the disability confined to either single extremity would have rendered the CI incapable of performing his MOS; but, it is equally speculative to conclude that it required a combined effect to render him unfit. Fitness considerations notwithstanding, it is difficult to reconcile analogous coding as arthritis with the pathology in this case. There is no joint disability to rate, since the pain and limitations were attributed to muscle disorder. Although the VA’s separate ratings were under the analogous code 5262 (tibia and fibula, impairment of), the rated disability under that code depends upon contiguous joint disability. All members agreed that there was a compelling indication for rating under the applicable muscle disability code; which, in this case is 5312 (Group XII, anterior muscles of the leg). Analogous rating is permissible IAW VASRD §4.20 only “when an unlisted condition is encountered.” A muscle syndrome involving a distinctly identified muscle group is clearly in evidence, and a conclusion that the disorder is ‘unlisted’ is overly tenuous. Furthermore, VASRD §4.55 (principles of combined ratings for muscle injuries) stipulates that “each muscle group injury shall be separately rated.” Therefore, a combined bilateral rating is not countenanced by the VASRD in this case, regardless of any speculative argument that neither extremity was separately unfitting.

Having agreed that separate ratings under 5312 were indicated, the Board deliberated the appropriate ratings under that code. Members agreed that severity and limitations were identical for each leg, and thus the ratings would be logically equivalent. Code 5312 yields ratings based on ‘slight’, ‘moderate’, ‘moderately severe’, and ‘severe’ muscle disability; rated 0%, 10%, 20%, and 30% respectively. Intrinsic to muscle disability rating descriptions is the presence of cardinal signs and symptoms, defined in VASRD §4.56 as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement”. Of these, the evidence indicates that only ‘lowered threshold of fatigue’ and ‘fatigue-pain’ were present. The §4.56 ‘slight’ rating description cites “healing with good functional results” and “no cardinal signs or symptoms”; and, the evidence makes clear that it was exceeded. The ‘moderate’ description cites “consistent complaint of one or more of the cardinal signs and symptoms ..., particularly lowered threshold of fatigue after average use.” The ‘moderately severe’ description cites “consistent complaint of one or more of the cardinal signs and symptoms ... and, if present, evidence of inability to keep up with work requirements.” The ‘severe’ rating requires more cardinal signs and symptoms, and cites a host of associated physical findings - none of which are in evidence. Deliberations thus settled on arguments for a ‘moderate’ 10% recommendation vs. a ‘moderately severe’ 20% recommendation. The moderate description emphasizes the cardinal sign which was dominant in this case (lowered threshold of fatigue); and, given that the CI’s symptoms surfaced with fairly strenuous activities, it was concluded that they would not interfere with average work requirements as per the moderately severe description. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that the disability was best aligned with the §4.56 ‘moderate’ criteria; and, the Board recommends separate right and left ratings of 10% for the bilateral lower extremity exertional compartment syndrome.


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. As discussed above, PEB reliance on the USAPDA pain policy for its rating was operant in this case, and the condition was adjudicated independently of that policy by the Board. In the matter of the Service-combined bilateral lower extremity exertional compartment syndrome, the Board unanimously recommends that each extremity be rated as separately unfitting at 10%, coded 5312, IAW VASRD §4.56. 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
Exertional Compartment Syndrome, Left Leg 5312 10%
Exertional Compartment Syndrome, Right Leg 5312 10%
COMBINED (w/ BLF)
20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120828, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record



                          
         XXXXXXXXXXXXXXXX, DAF
         President
         Physical Disability Board of Review
SFMR-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 XXXXXXXXXXXXXXXXXXXXXXXXX, AR20130021910 (PD201201359)


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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

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