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AF | PDBR | CY2013 | PD2013 00129
Original file (PD2013 00129.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1300129
BRANCH OF SERVICE: Army  BOARD DATE: 20130514
SEPARATION DATE: 20050607


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (88N/Transportation Management Coordinator) medically separated for bilateral leg pain. She first experienced mild leg pain in 1994 during basic training which did not affect the performance of her duties. The condition worsened in 1996 to the point where the CI was referred to an orthopedic specialist who diagnosed compartment syndrome. The CI underwent surgery in the right leg for compartment release in late 1996 followed by the same surgery in the left leg in early 1997. Despite these surgeries and other treatment the leg conditions could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The leg condition, characterized as “chronic bilateral lower extremity pain, s/p fasciotomies”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “chronic bilateral lower extremity pain…” as unfitting and rated 10% per the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “Compressed compartment syndrome in legs and carpal tunnel syndrome in both wrists. I also suffer from severe depression and Hepatitis C. I also have severe back pain and arthritis.” [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 rating for the unfitting bilateral leg condition is addressed below. The contended conditions of carpal tunnel syndrome, depression, Hepatitis C, back pain and arthritis were not identified by the PEB and are therefore not within the 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 PEB – Dated 20050217
 VA - (~2 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Lower Extremity Pain… 5099-5003 10% Status Post Fasciotomy, Right Lower Extremity… 5099-5019 10% 20050401
Status Post Fasciotomy, Left Lower Extremity… 5099-5019 10%
No Additional MEB/PEB Entries
 Other x 13
Combined: 10%
 Combined: 70%
Derived from VA Rating Decision (VA RD ) dated 200 50823 .


ANALYSIS SUMMARY: The PEB combined the bilateral lower extremities condition as a single unfitting condition, coded analogously to 5003 and rated 10%. The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VASRD sections. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each ‘unbundled’ condition was unfitting in and of itself or at least an indispensable element of a combined effect rating. Thus the Board must maintain the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Chronic Bilateral Leg Pain. The narrative summary (NARSUM) noted the CI reported bilateral leg pain and swelling without trauma history, associated with physical training while in basic training 1994. She did not improve with conservative treatment, thus, was referred to orthopedics. The CI was diagnosed with bilateral compartment syndrome and she underwent surgery of the right leg in November 1996, with the left leg undergoing a similar surgery in March 1997. She had no improvement after surgery and was placed on permanent L2 profile with return to duty. Her profile allowed her to walk at her own pace and distance. Radiographs of the left tibia/fibia March 2000 were normal. Treatment records related to the profiled condition were silent for both legs from August 1997 until July 2003. Orthopedic consultation 15 July 2003 noted tenderness to palpation of both legs and assessed fibula/tibula stress fractures, “pain not resolving.” The CI reported pain level of 8 out of 10. On 18 November 2004 bilateral lower leg radiographs were normal; a bone scan 24 November 2004 suggested moderate post-traumatic change or stress-related injury in the left knee tibial tuberosity region, otherwise there was no evidence of stress reaction or stress fractures. 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 chronic bilateral lower leg pain and assigned L3 designation. Her profile allowed sit-ups, pushups, Army Physical Fitness Test walking, biking, and she could walk at own pace and distance. At the MEB/NARSUM, 18 November 2004, on physical examination there was tenderness to palpation in both lower legs. The CI was able to heel, toe, and duck walk with lower extremity pain being worse with heel walk. The remainder of the exam was normal. Pedal and tibial pulses were normal, and she had normal sensation with no evidence of neuropathy. The VA Compensation and Pension examination, 1 April 2005, noted the CI reported bilateral lower leg pain with swelling and difficulty walking or standing for prolonged periods of time due to the pain and swelling. The CI reported no loss from work for the condition. Physical examination recorded normal gait, no signs of abnormal weight bearing, or muscle weakness. Examination of both right and left tibia/fibula were normal. Examination of right and left knee range-of-motion (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, 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. Examiner opined the scars caused no functional impairment. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the conditions and rated analogously using the 5003 code (degenerative arthritis) at 10% pain bilateral lower extremities. The VA rated each extremity at 10% for pain analogously and applied code 5019 bursitis (arthritis). The Board then undertook to unbundled the bilateral lower extremity condition, and noted all treatment entries referencing the condition were evaluated as a combined condition. Each extremity was discussed equally and was reported to have been equally painful. The Board determined the record in evidence reasonably supported that both lower extremities were unfitting. The Board undertook the rating of each extremity. In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. On review of the records the Board attempted to separate the extremities and was unable to determine that one extremity was more symptomatic than the other. There was no entry that referred to an individual painful extremity; both were referenced in all treatment records of evidence. There was insufficient evidence in the record of evidence to support the minimal compensable rating for each extremity. A compensable rating under either code requires documented evidence of incapacitating exacerbation, which was not supported by the record at hand. The NARSUM noted bilateral lower leg pain (reported by the CI and found during examination). The treatment records recorded multiple entries with report of bilateral leg pain. Gait was consistently recorded as normal, there was no evidence of incapacitating exacerbations, no quarters ordered, no visits to 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 rating code option 5260, 5261 or 5258. Additionally, there was no evidence of ratable peripheral neuropathy, no objective findings of painful motion to support the use of any other VARSD applicable code. Therefore, 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.


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 DoDI 1332.39 for rating bilateral lower extremity was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the bilateral extremity pain 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
Chronic Bilateral Lower Extremity Pain 5099-5003 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130324, 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 AR20130012145 (PD201300129)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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