RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00432
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Infantry) medically separated for a right hip, bilateral thigh [bilateral knee] and bilateral shin splints.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for an Medical Evaluation Board (MEB).  The persistent right groin pain, persistent bilateral knee pain and persistent bilateral shin pain conditions, characterized as “persistent right groin pain in face of healing stress fracture of right inferior pubic ramus”, “persistent bilateral knee pain with bone scan changes suggestive of bilateral distal thigh splints” and “persistent bilateral shin pain, greater left than right, with bone scan changes suggestive of left proximal tibial metaphysis”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated stress fracture diagnosed by bone scan (right inferior pubic ramus), bilateral distal thigh splints [bilateral knee pain] and bilateral shin splints as unfitting, rated 0% with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I would like all conditions (MEB/PEB) considered for being unfit for duty and rated to be reviewed.”  His complete submission is at Exhibit A.

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 condition 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 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:

Service IPEB – Dated 20070828	VA* - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Pubic Ramus Stress Fracture; Bilateral Thigh Splints [Bilateral Knee Pain], Bilateral Shin Splints	5022	0%	Stress Fracture, Right Pubic Rami, Distal Femur, and Tibia	5099-5255	0%	20080122	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1		
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20080703 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The PEB combined the right hip stress fracture, bilateral distal thigh [bilateral knee] and shin splints and rated them as a single unfitting condition.  The Board’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  The evidence for the right hip stress fracture, bilateral distal thigh [bilateral knee] and shin splints are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Right Pubic Ramus Stress Fracture.  The service treatment record (STR) and MEB narrative summary (NARSUM) documented an initial evaluation in March 2007 (6 months pre-separation) for right hip pain that occurred during basic training from running up and down stairs, completing an obstacle course and worsened after he fell on the right hip.  Radiographic evaluation of the right hip documented normal bones, joints, and soft tissues without evidence of fracture or dislocation.  A bone scan in April 2007 (5 months pre-separation), obtained for continued right hip and groin pain documented a stress fracture of the right pubic bone.  Radiographic evaluation in May 2007 (4 months pre-separation) documented a healing stress fracture of the right pubic bone.  During a physical therapy visit on 8 May 2007, the CI reported an attempt to ambulate without crutches, but had to use them due to pain.  A second physical therapy exam on 22 May 2007 documented similar findings:  tenderness to palpation of the proximal femur (upper thigh); and painful motion of the bilateral hips at “extreme” internal rotation and external rotation.

The MEB NARSUM exam was performed on 11 July 2007 (2 months pre-separation).  The CI reported daily right groin pain rated 3/10, that worsened (7/10) with ambulation, marching and prolong standing.  The examiner documented a “smooth” gait with 30 degrees of external rotation (normal 45) of both lower extremities on ambulation and stance.  The right groin was tender to palpation with no swelling.  Testing of strength and sensation were normal.  A referral was made to orthopedics for continued pain with ambulation, use of crutches, and inability to complete training.  A physical therapy visit in July 2007 documented right hip flexion of 90 degrees (normal 125), extension was 0 (normal 20) and abduction was 23 (normal 45).  There was no limitation of adduction (crossing of the legs) or inability to rotate the hip (“toe out”).

The VA rating decision documented pertinent evidence of the VA Compensation and Pension (C&P) exam performed on 22 January 2008.  The CI had reported pelvic and hip pain, every 2-3 weeks, lasting hours.  The VA examiner documented a normal gait, no evidence of painful motion or limited motion, and no additional losses on repetitive use.  The examiner documented normal radiographs of the hip and pelvis.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the right hip stress fracture together with the bilateral distal thigh and shin splints as unfitting, gave a 0% rating citing no limitation of motion, and coded 5022 (periostitis).  The VA granted a 0% rating coded 5255 (Femur, impairment of) for the left hip and lower extremity conditions and a 0% rating for the right hip and lower extremity conditions, analogous coded as 5099-5255.

The Board first considered if the right hip condition, after being de-coupled from the combined PEB adjudication, remained itself unfitting as above.  In this case, the right hip condition was profiled, considered to fail retention standards, and was implicated by the commander’s statement and NARSUM.  Members agreed the right hip condition was reasonably justified as separately unfitting and eligible for service rating.

There was no documentation of hip ankylosis, limitation of abduction beyond 10 degrees, inability to cross the legs (adduction), limitation of rotation, or abnormal extension in support of alternate coding resulting in a rating higher than 10%.  There was no evidence of fracture or malunion of the femur.  Members agreed that there was sufficient evidence of painful motion and limited range of motion prior to separation in support of a 10% rating, analogously coded 5099-5022 (periostitis) or 5299-5252 (thigh, limitation of flexion).  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 hip condition.

Bilateral Distal Thigh Splints [Bilateral Knees], and Bilateral Shin Splints.  A bone scan in April 2007 (5 months pre-separation), obtained for hip and groin pain, documented “suggestion of early probable stress fracture” of the left lower extremity (proximal tibial [shin] shaft) and bilateral distal thigh splints.  Radiographic evaluation in May 2007 (4 months pre-separation) documented a normal left lower extremity (tibia and fibula).  During a physical therapy visit in May 2007, the CI reported an attempt to ambulate without crutches but “had to use them due to pain;” however did not elaborate regarding the area of pain.  A second physical therapy visit in May 2007 documented similar findings:  an antalgic gait; “normal motion” of both knees, the left hamstring muscle was considered “weak due to pain,” and tenderness of the bilateral shins.

During the MEB DD Form 2807-1, Report of Medical History, dated 18 June 2007, the CI reported “slight” pain in the knees, and “tingling sensation in the tibias” after excessive walking.  The MEB DD Form 2808, Report of Medical Examination, was dated 18 June 2007.  The examiner did not elaborate on the “abnormal” lower extremity exam.  During a separate MEB physical exam on 27 June 2007, the examiner documented no crepitus or tenderness on ambulation and did not elaborate any other “abnormalities” noted on palpation of the lower extremities.

During the MEB NARSUM exam the CI reported pain in both knees and shins rated at 3/10 every day which increased to 7/10 with ambulation, marching, and prolonged standing.  The examiner documented a “smooth” gait, normal strength and sensation, and symmetric knees with no swelling or muscular atrophy.  There was tenderness over both patellae (knee caps) and just below the left knee.  The next day, a physical therapy exam documented right knee flexion of 138 degrees (normal 140); left knee flexion of 140 degrees; bilateral extension to 0 degrees (normal 0); with pain limiting motion.  There was less than 5mm of laxity of the bilateral knees (Lachman stability testing).

During the VA C&P exam performed on 22 January 2008 the CI had reported knee and shin pain every 2-3 weeks, lasting hours.  The VA examiner documented no evidence of painful motion, instability, antalgic gait, limited motion, and no additional losses on repetitive use.  Radiographs of the knees and tibia were normal.  The examiner concluded that the exam was normal and diagnosed “healing stress fractures, both...distal femurs and tibia.”
The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the bilateral distal thigh [bilateral knees] and shin splints as unfitting, gave a 0% rating citing no limitation of motion, and coded 5022 (Periostitis).  The VA granted a 0% rating coded 5255 (Femur, impairment of) for the left hip and lower extremity conditions and a 0% rating for the right hip and lower extremity conditions, analogous coded as 5099-5255.

The Board considered if the bilateral thigh and knee condition, after being de-coupled from the combined PEB adjudication would remain unfitting.  In this case, the bilateral knees were profiled, considered to fail retention standards, and were implicated in the commander’s statement and NARSUM.  Member consensus was therefore that the bilateral thigh and knee conditions were reasonably justified as separately unfitting and eligible for rating.

The Board discussed if there was sufficient evidence of painful motion IAW VASRD §4.59 [including §4.40 (Functional loss) and §4.45 (The joints)] to warrant separate ratings for the right and left knees.

The right knee was documented with tenderness on palpation (thigh and medial knee).  There was some evidence of slightly reduced range-of-motion (ROM) and pain limited ROM prior to separation.  The knee pain persisted with use after separation.  There was no evidence of flexion limited to 45 degrees, extension limited to 10 degrees, or ankylosis for a higher rating.  Other coding options were considered, however, none were found to be of benefit to the CI.  After due deliberation, considering all of the evidence, mindful of VASRD §4.3 (Reasonable doubt), and IAW VASRD §4.59, §4.40, and §4.45, the Board unanimously recommends a disability rating of 10% for the right thigh and knee condition coded analogously as 5099-5022 (Periostitis).

The left knee radiographic evidence displayed left femur and shin splints.  There was documented tenderness on palpation of the left knee prior to separation.  There was secondary muscle weakness attributed to pain in the left knee.  The NARSUM and physical therapy exams documented tenderness and pain limited motion, respectively; which resolved after separation.  The Board agreed there was no ROM evidence to grant a compensable rating with codes 5260 (Limitation of flexion) or 5261 (Limitation of extension); and no evidence to rate code 5262 (Tibia and fibula, impairment of) at 10% (slight).  After due deliberation, considering all of the evidence, mindful of VASRD §4.3 (Reasonable doubt), and IAW VASRD §4.59, §4.40, and §4.45, the Board unanimously recommends a disability rating of 0% for the left knee coded analogously as 5099-5022 (Periostitis).

The Board next considered if the bilateral shins condition, after being de-coupled from the combined PEB adjudication would remain unfitting.  In this case, the bilateral shins were profiled, considered to fail retention standards, and were implicated in the commander’s statement and NARSUM.  Members thus agreed therefore that the bilateral shin conditions were reasonably justified as unfitting and eligible for disability rating.

The Board discussed if there was sufficient evidence of painful motion IAW VASRD §4.59 to warrant separate ratings for the bilateral shins.  In this case, there were no significant distinctions with regards to the clinical features of the right and left shins.  Treatment records indicated bilateral shin pain with use.  Radiographic evaluation in May 2007 (4 months before separation) documented a normal left lower extremity (tibia [shin] and fibula).  One physical therapy evaluation in May 2007 documented an antalgic gait; and tenderness of the bilateral shins.  The CI reported pain in both shins rated at 3/10 every day which increased to 7/10 with ambulation, marching, and prolonged standing.  The examiner documented a “smooth” gait, normal strength and sensation, with no redness or swelling of the legs.  The examiner diagnosed persistent bilateral shin pain, left greater than right.  At the VA C&P exam the CI reported bilateral shin pain every 2-3 weeks, lasting hours.  The VA examiner documented no evidence of painful motion, instability, antalgic gait, limited motion, and no additional losses on repetitive use.  Radiographs of the knees and tibias [shins] were normal.  The examiner concluded that the exam was normal and diagnosed “healing stress fractures, both... tibia [shin].”  The VA granted a 0% rating for right and left lower extremities.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), and IAW VASRD §4.59, the Board unanimously recommends a single disability rating of 0% for the bilateral shins coded analogously as 5022-5003 (Periostitis).

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 hip condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5022 (periostitis) IAW VASRD §4.71a.  In the matter of the bilateral knee conditions, Board members agreed that it was separately unfitting and recommend a disability rating of 10%, for the right knee condition and 0% for the left knee condition, both coded 5099-5022 IAW VASRD §4.71a.  In the matter of the left and right shin splint conditions, the Board unanimously agrees that it was unfitting and recommends a single disability rating of 0%, coded 5099-5022 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:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Pubic Ramus Stress Fracture	5099-5022	10%	
Right Knee Stress Reaction	5099-5022	10%	
Left Knee Stress Reaction	5099-5022	0%	
Bilateral Shin Splints	5099-5022	0%	
COMBINED w/BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130131, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXX, AR20160002166 (PD201400432)

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:

CF: 
(  ) DoD PDBR
(  ) DVA