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AF | PDBR | CY2014 | PD-2014-01989
Original file (PD-2014-01989.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-01989
BRANCH OF SERVICE: Army  BOARD DATE: 20150508
SEPARATION DATE: 20060201


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Infantryman) medically separated for right common peroneal neuropathy with weakness and sensory impairment, and right leg healed stress fractures. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “chronic right leg pain due to stress fractures” and “right common peroneal nerve palsy” conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB (IPEB) adjudicated the right leg neuropathy and right leg healed stress fractures as unfitting, rated 10% and 0% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated. The CI recovered enough to enlist in the Army again in 2008 and serve for more than 3 years including a 12-month tour in Iraq. He separated from the Army on 3 April 2011. The Board’s review is for the period of service that resulted in the 2006 discharge with disability severance pay.


CI CONTENTION: “Please consider all conditions.”


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 :

IPEB – Dated 20051213
 VA* – ~2 Mos. Pre-Separation
Condition
 Code Rating Condition Code Rating Exam
Right Common Peroneal Neuropathy… 8521 10% Right Common Peroneal Nerve Palsy 8521 20% 20051122
Stress Fractures…Right Leg… 5022 0% Stress Reaction of Right Knee… 5099-5022 0% 20051122
Stress Fractures Right Leg 5099-5010 NSC 20051122
Other x 0 (Not In Scope)
 Other x 0
COMBINED: 10%
 COMBINED: 20%
* Derived from VA Rating Decision (VA RD ) dated 200 60221 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Right Common Peroneal Neuropathy. The narrative summary noted that during basic training in 2005 the CI developed pain in both lower extremities (LE). Notes in the service treatment record (STR) indicated the CI initially reported pain of the right knee and left ankle. Knee X-rays performed on 17 May 2005 were normal. Bone scan on 13 June 2005 noted bilateral stress reactions of the femurs (thigh) and tibiae (lower leg), discussed further below. At a physical therapy follow-up visit the CI reported the left ankle pain had resolved, but the right knee pain persisted and he was placed on convalescent leave due to the right stress fractures. After the CI returned to duty, he reported lack of coordination of the right foot when walking, with numbness of the toes. Magnetic resonance imaging (MRI) of the knee was normal and electrodiagnostic studies from 18 October 2005 noted a common peroneal neuropathy thought to be related to events that caused the stress fractures. Orthopedic evaluation on 28 October 2005 noted mildly decreased foot dorsiflexion (graded 5-/5) and great toe dorsiflexion (graded 4/5) and decreased sensation of the toes. There was full range-of-motion (ROM) of the knee with normal strength.

At the MEB examination on 4 November 2005, 3 months prior to separation, the CI reported foot weakness and numbness, aggravated by physical activity. The MEB physical exam noted mildly weak right ankle dorsiflexion and plantar flexion. Knee ROM was extension-flexion of 0 to 100 degrees (normal 0 to 140) and ankle ROM was dorsiflexion of 10 degrees (normal 20) and plantar flexion of 15 degrees, (normal 45). There was weakness of dorsiflexion and plantar flexion of the toes and decreased sensation in the first and second toes.

At the VA Compensation and Pension (C&P) examination on 22 November 2005, 2 months prior to separation, the CI reported difficulty walking and running due to ankle weakness, with numbness and tingling of the leg and foot. The CI did not use a cane or a crutch for ambulation. The exam noted an abnormal gait with slight right foot drop (weak dorsiflexion). Knee and ankle ROM was normal without painful motion noted. Ankle and great toe strength was decreased, with dorsiflexion graded 4/5. Sensation and reflexes of the right lower extremity (RLE) were normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the RLE neuropathy condition 10%, coded 8521 (incomplete paralysis of the common peroneal nerve) and the VA rated it 20% with the same code. The Board noted that the CI had two types of injuries of the RLE, nerve injury to the right common peroneal nerve and musculoskeletal injuries of stress fractures. The stress fractures are discussed further below. The evidence in record indicates that at the MEB exam 3 months prior to separation the CI’s common peroneal neuropathy was worse than it was a month later at the C&P exam. At the C&P exam the localized sensory deficits had resolved, but CI had improved knee and ankle ROM with persistent mild weakness of the foot. Members agreed that 8521 was the appropriate code to utilize and noted the rating criteria are subjective with a 10% rating for “mild,” 20% for “moderate,” and 30% for “severe” incomplete paralysis of the common peroneal nerve. The Board concluded that at the time of separation the neuropathy was improving and best characterized as mild, not moderate. After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the RLE neuropathy condition.

Right Leg Stress Fractures. As outlined above, the CI was diagnosed with right LE stress fractures during basic training. When he returned from convalescent leave for the stress fractures, he reported continued RLE pain. The exam noted tenderness to palpation (TTP) of the right knee with normal gait and ROM. X-rays of the tibia and fibula from 19 August 2005 showed a healing stress fracture of the tibia. An MRI of the knee was reported as normal. Serial knee X-rays were normal, but the CI continued with RLE pain that limited weight bearing activities. The permanent profile listed “chronic (R) leg pain due to stress fracture” and “foot drop/numb toes due to nerve irritation.” There were two versions of the commander’s statement, both dated 1 November 2005, one indicated that the CI could not participate in physical activities due to the right tibial stress fracture and the second referred only to his “injury,” without additional description.

At the MEB examination on 4 November 2005, 3 months prior to separation, the CI reported continued RLE pain with exercise and noted that all other pain had resolved. The MEB physical exam noted TTP of the right tibia in the area of the stress fracture, without swelling, bruising, or abnormal sensation. There was limited knee and ankle ROM as noted above in the neuropathy discussion. The examiner indicated ROM was not limited by pain, but the CI could not run or bicycle due to RLE pain.

At the VA C&P examination on 22 November 2005, 2 months prior to separation, the CI reported constant right knee and leg pain that did not cause incapacitation. The exam noted normal gait. The knee appeared normal with TTP of the femur and tibia at the inside of the knee. Knee ROM was normal, without painful motion or evidence of instability or semilunar cartilage damage. There was full ROM of the ankle without painful motion or evidence of additional loss of ROM with repetition. The exam noted that the knee MRI of 14 October 2005 indicated an equivocal finding consistent with a bone bruise or stress reaction of the medial femoral condyle. Right knee and tibia/fibula X-rays were within normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB and VA both rated the RLE stress fractures condition 0%, coded 5022 (periostitis) by the PEB and 5099-5022 by the VA. As noted above the CI had two types of injuries of the RLE, the right common peroneal neuropathy and stress fractures. After deliberations, the Board agreed with the PEB adjudication of the neuropathy condition and recommended no change to the 10% rating IAW §4.124a. The Board discussed whether an additional rating of the RLE IAW §4.71a based upon pain, constituted pyramiding, and is therefore not sanctioned IAW VASRD §4.14 (avoidance of pyramiding). However, the evidence supports that the neuropathy condition caused weakness, which in itself caused unfitting impairment of the RLE. Therefore, Board consensus was that additional rating of the RLE for disability due to symptoms other than weakness was not necessarily precluded by the §4.124a rating.

The Board considered that the RLE pain due to stress reactions preceded the development of the neuropathy symptoms and diagnosis by months. At both the MEB and C&P exams the CI reported significant pain with use of the RLE and both the MEB and C&P exams noted TTP in the area of the stress fractures of the RLE. The Board consensus was that the residual bony tenderness of the right knee and leg at both the MEB and C&P exams supported a 10% rating coded as 5022 for pain with use IAW §4.40 (functional loss) which states that “a part which becomes painful on use must be considered as seriously disabled.” The Board briefly noted that the VA provided a 20% rating for moderate neuropathy and agreed that the combined rating of 20% could be achieved this way, if all of the RLE symptoms are considered secondary to the neuropathy. However, based on the evidence of separately diagnosed conditions, each objectively substantiated by testing, the Board preferred the approach of rating the two separately unfitting conditions according to their contribution to the CI’s disability at separation. The Board reviewed to see if a higher evaluation was supported with any other applicable code. The knee and ankle ROM was reduced at the MEB, but was normal at the prior-to-separation C&P exam, and was likely related to the gradually improving LE neuropathy. There was no evidence of ankylosis, instability, or injury of the semilunar cartilage, or femur or tibia/fibula impairment with moderate ankle or knee disability to recommend a higher rating utilizing a knee code, and no evidence of marked limited ankle motion or malunion or deformity of the ankle to recommend a higher evaluation with an ankle code. 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 RLE stress fracture 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. 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 RLE neuropathy condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the RLE stress fractures condition, the Board unanimously recommends a disability rating of 10%, coded 5022 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:

CONDITION
 VASRD CODE RATING
Right Common Peroneal Neuropathy Condition 8521 10%
Right Leg Healed Stress Fractures 5022 10%
COMBINED
 20%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140505, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record









XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXXXXXXX , AR20150014203 (PD201401989)
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 of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA


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