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AF | PDBR | CY2013 | PD-2013-02208

Original file (PD-2013-02208.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXXX CASE: PD-2013-02208
BRANCH OF SERVICE: Army BOARD DATE: 20150624

SEPARATION DATE: 20080630

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty 0-3 (Signal, General) medically separated for lower extremity pain. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS). The CI was profiled to take an alternate aerobic event to satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “bilateral lower extremity exertional compartment syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded eight other conditions (see rating chart below) for PEB adjudication. The Informal PEB adjudicated fit for duty. The CI appealed to the Formal PEB (FPEB) which adjudicated “bilateral lower extremity compartment syndrome…” as unfitting, rated 20% c iting application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting and the CI was medically separated.

CI CONTENTION: “MEBD DIAG 2 Peroneal Nerve Distal & MEBD DIAG 3-10: Depression, bilateral carpal tunnel syndrome, bilateral hip pain, fibrocycsic breast disease, back pain, headaches, menstrual pain, and chronic PTSD. Were listed as not unfitting and not rated in the PEB. However, upon discharge the VA rated these dsaibilities for a total of 90% upon service members discharge. These ratings should have been included in the PEB.” [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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON :

FPEB – Dated 20080312	VA* - (~6 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Bilateral Lower Extremity Compartment Syndrome	5399-5312	20%	Residuals of Tibial Fasciotomies (Left Lower Leg)	5399-5311	10%	20071207
			Residuals of Tibial Fasciotomies (Right Lower Leg)	5399-5311	10%	20071207
			Neuralgia Right Peroneal Nerve	8599-8521	10%	20071207
Menstrual Pain	Not Unfitting	Dysmenorrhea	7699-7613	10%	20071207
Bilateral Carpal Tunnel	Not Unfitting	Right Carpal Tunnel Syndrome	8515	10%	20071207
		Left Carpal Tunnel Syndrome	8515	10%	20071207
Bilateral Hip Pain	Not Unfitting	Left Hip…Trochanteric Bursitis	5019-5252	10%	20071207
Fibrocystic Breast Disease	Not Unfitting	Fibrocystic Breast Disease	7699-7628	NSC	20071207
Chronic Low Back Pain	Not Unfitting	Lumbar Strain	5237	10%	20071207
Headaches	Not Unfitting	Tension Headaches	8199-8100	0%	20071207
Depression, NOS	Not Unfitting	Post Traumatic Stress Disorder and Depression	9434-9411	30%	20071207
Chronic PTSD, Remission	Not Unfitting
Other x 0 (Not In Scope)	Other x 10 (Not in Scope)
RATING: 20%	RATING: 80%

* Derived from VA Rating Decision (VA RD ) dated 200 80709 ( most proximate to date of separation ( DOS ) ) .

ANALYSIS SUMMARY:

Bilateral Lower Extremity Compartment Syndrome. The narrative summary (NARSUM) noted a 5-year history of bilateral lower extremity pain brought on by exercise. The CI was diagnosed with bilateral compartment syndrome and underwent surgery (fasciotomy) of the both legs in October 2002 and again in December 2004. Post-surgery, the CI continued to have intermittent pain that increased with activity, and after the second surgery she has had problems with hyperesthesia in the right foot/distal leg. Neurology clinic entry dated 3 April 2006 recorded sensory changes in the right leg in the distribution of the peroneal nerve. Nerve conduction and electromyogram studies were abnormal; both suggested chronic denervation in the area distal to or in the incision cite. Magnetic resonance imaging (MRI) of the right lower extremity, 14 June 2007, was unremarkable with the exception of a focal myositis of the soleus muscle. The CI was treated with a TENS unit and medication for her right leg neuropathic pain (numbness and tingling). She participated in physical therapy with limited benefit. She underwent consultation with physical medicine and rehabilitation on 23 July 2007 and was referred to the MEB secondary to chronic pain brought on with running or fast walking, unresolved with treatment. There were no entries in the treatment records documenting muscle weakness, atrophy, radiation of pain, episodes of knee locking, disturbance of gait, limitation of motion, knee or ankle instability, or effusions. The CI’s profile listed bilateral lower extremity compartment syndrome and assigned L3 designation. Her profile allowed sit-ups, pushups, upper and lower body weight training, swimming, and she could walk at her own pace and distance. At the NARSUM dated 5 December 2007, and conducted on 24 October 2007 (8 months before separation), the CI reported her pain in both legs had caused weakness at times; the right lower extremity had caused some numbness and tingling with pain as great as 7/10. The examiner noted orthopedics had confirmed that she had exercise-induced symptoms. The CI had not passed a PFT since July 2007. On physical examination, gait was recorded as normal and tone in the lower extremities was within normal limits. There was no evidence of muscle atrophy, muscle strength was normal, and sensory examination was grossly intact with the exception of hyperesthesia in the peroneal sensory distribution of the lower legs and the anterior aspects of the ankles. Range-of-motion (ROM) was not recorded. There was tenderness to light palpation on the right lower extremity adjacent to the surgical scar. The diagnoses of bilateral lower extremity exertional compartment syndrome (moderate/constant) and “electrophysiologic evidence of chronic right lower extremity neuropathy of the peroneal nerve” were assessed.

The VA Compensation and Pension (C&P) examination performed on 12 December 2007 (6 months before separation), noted the CI reported bilateral lower leg pain that traveled up the legs, characterized as squeezing, aching, sharp and cramping, with pain intensity of 8-10/10. Her pain was relieved with rest and with Motrin. She indicated that she had swelling with ambulation, and that she could only stand or walk for 20 minutes. Physical examination noted tenderness to palpation in the lower anterior and lateral legs secondary to fasciotomies, and generalized tenderness to the tibia and fibula. Examination of right and left knee ROM noted normal flexion and extension with no limitation of motion by pain, fatigue, weakness, or repetition. Right and left ankle joint were noted equally with dorsiflexion of 20 degrees (normal), plantar flexion 45 degrees (normal) and no additional limitation due to pain, fatigue, weakness, or repetition. No evidence of knee or ankle instability or painful ROM. Surgical scars were healed without ulceration, edema, and tenderness.

The Board directed attention to its rating recommendation based on the above evidence. The PEB combined the conditions, but noted each extremity was rated separately at 10%. The PEB coded the condition analogously, 5399- 5312 (Muscle group XII, moderate impairment), noted the application of §4.40 (functional loss) for each extremity, and combined 10% to arrive at a 20% evaluation for the bilateral lower extremities. Likewise, the VA rated each extremity at 10% for pain; however, used a different code, 5311 (Muscle group XI, moderate impairment). All Board members agreed that the 10% criterion was met for each extremity. A higher rating under either code requires documented evidence that the condition demonstrated impaired muscle function of moderately severity; not supported by the record at hand. The NARSUM noted bilateral lower leg pain associated with exertion, and some tenderness in the right lower leg, absence of atrophy, weakness and tropic changes. The NARSUM examiner noted that the CI was unable to run or walk at a fast pace without pain. The C&P examination documented generalized tenderness. There was no evidence of visits to the emergency room specifically for lower extremity pain, and all ROMs recorded were full. Therefore, the Board concluded there was no evidence in the treatment record that would support a rating greater than 10% for each extremity. There were no additional codes to consider. Thereupon, 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 bilateral lower extremities condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of “electrophysiologic evidence of chronic right lower extremity neuropathy of the peroneal nerve… exertional right lower extremity pain”, depression, NOS, in partial remission, bilateral carpal tunnel syndrome, bilateral hip pain, fibrocystic breast disease, chronic low back pain, headaches, menstrual pain (severe), and chronic PTSD, in remission, were not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board noted with the conditions “electrophysiologic evidence of chronic right lower extremity neuropathy of the peroneal nerve… exertional right lower extremity pain”, bilateral carpal tunnel syndrome, bilateral hip pain, fibrocystic breast disease, chronic low back pain, headaches, menstrual pain (severe), and chronic posttraumatic stress disorder (PTSD), in remission, were not profiled or implicated in the commander’s statement. All were reviewed and considered by the Board. There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. The Board reviewed the record in evidence and noted the condition of depression, NOS, in partial remission, was listed on the profile, as an S1 condition with no mental health associated duty restriction. Mental health treatment entry in October 2007 documented the CI reported that she “noticed near resolution of her depressive symptoms while on leave from the military.” She had not experienced any PTSD symptoms for over a month, but had some mildly impaired concentration and low energy, and some sleep difficulty which she attributed to “jet lag.” The CI was taking an antidepressant medication and felt that the medicine had been helpful. The examiner stated, “She (the CI) concurs that she is probably psychiatrically fit to continue on active duty.” The record also documented that the CI was diagnosed with PTSD after an attempted sexual assault while deployed in 2003. The CI was able to prevent the assault when she produced her weapon. There was no performance based evidence from the record that any mental health 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 any of the contended conditions and so no additional disability ratings are 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 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 bilateral lower extremity exertional compartment syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended “electrophysiologic evidence of chronic right lower extremity neuropathy of the peroneal nerve… exertional right lower extremity pain”, depression, NOS, in partial remission, bilateral carpal tunnel syndrome, bilateral hip pain, fibrocystic breast disease, chronic low back pain, headaches, menstrual pain (severe), and chronic PTSD, in remission conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131101, w/atchs
Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXX , AR20150012459 (PD201302208)

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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl                                                  XXXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2013 | PD-2013-02208

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