RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00437
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E2, Administrative Specialist, medically separated for “left hip, bilateral knee, bilateral stress fractures and bilateral ankle conditions,” with a combined disability rating of 0%

CI CONTENTION:  The CI contends his left hip and bilateral knee pain continues to limit his daily activities.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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 PEB - 20070406	VARD - 20080527	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Trochanteric Bursitis	5019	0%	Trochanteric Bursitis Left Hip	5252-5024	10%	20080423	
Bilateral PFS	5099-5003	0%	PFS Right Knee	5260-5024	0%		
Tibial Stress Fracture	5022	0%	PFS Left Knee w/History of Tibial Stress Fracture	5260-5024	10%		
Chronic Ankle Pain	5099-5003	0%	Right Tibial Stress Fracture w/History of Ankle Pain	5262	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Hip Trochanteric Bursitis.  The service treatment record (STR) and narrative summary (NARSUM) documented the onset of atraumatic left hip pain in October 2006, (1 month after entry).  At a primary care visit in January 2007 (3 months pre-separation), the CI reported gradual onset of left hip pain that worsened with extended activity.  The examiner documented tenderness with ambulation, tenderness of the lateral hip and thigh muscles, “abnormal” flexion, and normal internal and external rotation of the hip.  On a follow-up visit 12 days later, the CI reported continued left lateral hip pain.  The examiner diagnosed “trochanteric bursitis” after documenting tenderness of the lateral hip (trochanteric bursa), antalgic gait, painful motion with “abnormal” hip motion, and no instability.  On the Medical Evaluation Board (MEB) DD Form 2807-1, Report of Medical History, dated 28 February 2007 (2 months pre-separation), the CI reported use of ambulatory aids (crutches for 3 months and continued cane use).  On the MEB DD Form 2808, Report of Medical Examination, dated 28 February 2007 (2 months pre-separation), the examiner documented tenderness of the hip and inguinal region, flexion to 97 degrees (normal 125), extension to 17 degrees (normal), abduction to 33 degrees (normal 45), adduction to 35 degrees (normal 45), and external rotation (“out toeing”) to 45 degrees (normal).  

The MEB NARSUM examination was performed on 14 March 2007 (1 month pre-separation).  The examiner documented that the CI was “ambulating well,” with normal motor and sensory examination.  There was tenderness over the hip and groin region.  Range-of-motion (ROM) was identical to those listed on the DD Form 2808.  At a primary care examination in August 2007 (4 months post-separation), the CI reported dislocation of the hip and “having to push it back in at times.”  The examiner documented a “coordinated and smooth” gait, no weakness, and with full painless ROM of the joints.  At a primary care examination in March 2008 (11 months post-separation), the CI reported that her left hip “pops out.”  The examiner documented tenderness to palpation, painful motion with strength testing, and no deformity, crepitus, or instability.  

At the VA Compensation and Pension (C&P) examination performed on 23 April 2008 (12 months post-separation), the CI reported an inability to stand more than 15-30 minutes, walk more than a few yards, use of an assistive device (brace) and that the hip was stiff, had intermittent effusion, and “pops out constantly.”  The examiner documented an antalgic gait with flexion to 100 degrees, extension to 17 degrees, with external rotation, abduction, and adduction to 35 degrees each, and pain with all movements.  Radiographic evaluation of the left hip was normal without evidence of stress fractures, bony abnormality, or joint effusion.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the left hip trochanteric bursitis as unfitting, rating 0% coded 5019 (bursitis) citing “without ratable limitation of motion.”  The VA rated 10% coded analogously as 5252-5024 (limitation of thigh flexion, tenosynovitis) citing painful and decreased range-of-motion.  The Board considered the evidence for a higher rating.  There was no STR evidence of flexion limited to 45 degrees (5252), or extension limited to 5 degrees (5251).  There was no evidence of limitations of abduction beyond 10 degrees, documentation of inability to cross the legs, or limitation of rotation more than 15 degrees in support of a higher rating under VASRD code 5253.  There was documentation of painful and decreased range-of-motion for a 10% rating analogously coded 5252-5019, as coded by the VA.  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 left hip trochanteric bursitis condition.  

Bilateral Patellofemoral Syndrome.  The PEB combined the bilateral knee conditions under a single 0% disability rating, coded analogously to 5099-5003 (degenerative arthritis).  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows individual ratings for each compensable joint in accordance with §4.7 (higher of two ratings).  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the Board judges that the bundled conditions are reasonably justified as separately unfitting, then separate ratings are recommended; with the stipulation that the result may not be lower than the combined rating from the PEB for the bundled conditions.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the bilateral knee conditions are presented; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

The STR and NARSUM documented the onset of atraumatic left knee pain in October 2006, (1 month after entry).  On an entry note in October 2006 (6 months pre-separation), the CI had reported 9 days of leg pains.  The examiner documented full ROM of the knees with crepitation under the patellar tendons.  There was no swelling and bony tenderness.  At a primary care visit in January 2007 (3 months pre-separation), the CI reported gradual onset of atraumatic bilateral knee pain since basic training and denied swelling and stiffness.  The examiner documented a slow gait, tenderness of the right knee (medially and laterally), and full ROM with pain.  At a follow-up visit 3 weeks later, the examiner documented tenderness of the knees on ambulation with normal appearance of the knees.  The left knee was tender laterally and on palpation of the infrapatellar tendon.  On the MEB DD Form 2807-1 the CI reported right knee pain, and the use of ambulatory aids (crutches for 3 months and continued cane use).  On the MEB DD Form 2808 the examiner documented bilateral knee effusions, tenderness of the patellar tendons, right knee ROM of 10-135 degrees (normal 0-140), and left knee ROM of 10-130 degrees.  There was no crepitus and no laxity (Lachman’s, drawer tests and varus and valgus stress testing).  

The MEB NARSUM examination was performed on 14 March 2007 (1 month pre-separation).  The CI reported bilateral knee pain.  The examiner documented tenderness of the patellar tendon, and joint line, some crepitus, with no edema, or effusion.  Right knee ROM was 10-135 degrees and left knee ROM was 10-130 degrees.  At a primary care examination in August 2007 (4 months post-separation), the CI reported dislocation of the left knee and having to “push it back in at times.”  The examiner documented a “coordinated and smooth” gait, no weakness, and with full painless ROM of the joints.  At a primary care examination in March 2008 (11 months post-separation), the CI reported that her left knee “dislocates,” and that it was painful at rest, and worsened with extension.  The examiner documented no deformity, crepitus, or instability of the left knee.  At the VA C&P examination performed on 23 April 2008 (12 months post-separation), the CI reported that the left knee was painful, stiff and weak, with effusion “all the time,” and “pops out constantly.”  The examiner documented that the CI was walking with a limp and a left knee brace.  Right knee ROM was 0-140 degrees without pain and without additional limitations after repetition.  Left knee ROM was 0-65 degrees with pain.  Radiographic evaluation of the left knee was normal without evidence of recent fracture, dislocation, or bony abnormality.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the bilateral patellofemoral syndrome as unfitting, rating 0% coded 5099-5003 (degenerative arthritis) citing “without ratable limitation of motion.”  The VA granted service connection for both knees and rated the left and right knee conditions separately.  A 10% rating was given for the left knee condition citing painful and decreased range-of-motion.  A 0% was given for the right knee condition, citing no evidence of chronic disability.  Both were coded analogously as 5260-5024 (limitation of leg flexion; tenosynovitis).  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, each joint must be reasonably justified as unfitting for separate disability ratings.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM; and, both were profiled.  The commander’s performance statement did not differentiate functional limitations attributable to the bilateral knee conditions.  There was scant STR evidence of any information which would permit the Board to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either would not have unacceptably interfered with performance, members agreed that each knee was reasonably justified as separately unfitting.  

A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the STR, MEB DD Form 2808, and the NARSUM provided satisfactory evidence for painful motion of both knees; thus, separate joint ratings are indicated IAW §4.71a.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends separate disability ratings of 10% for the left and 10% for the right knee conditions.  

Bilateral Stress Fractures.  The STR documented the first care for left leg pain in October 2006 (1 month after entry).  Radiographic imaging (bone scan) in January 2007 reportedly documented findings consistent with bilateral tibial stress fractures (“increased uptake” in the left mid tibia and proximal right tibia).  On the MEB DD Form 2807-1 the CI reported tibial fractures in the left leg, and the use of ambulatory aids (crutches for 3 months and continued cane use).  On the MEB DD Form 2808 the examiner documented tenderness of the bilateral tibias without edema.  The MEB NARSUM examination was performed on 14 March 2007 (1 month pre-separation).  The CI reported bilateral leg pain.  The examiner documented tenderness “over the anterior medial border, mid one third, with no edema, and her compartments are soft x 4.”  At the VA C&P examination performed on 23 April 2008 (12 months post-separation), the CI reported that the bilateral tibial stress fractures had healed and declined evaluation for the condition.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the “tibial stress fracture” as unfitting, rating 0% coded 5022 (periostitis) citing “without x-ray verification, without ratable limitation of motion.”  The VA granted service connection for the “right tibial stress fracture with history of ankle pain.”  A 0% was given for the right lower extremity condition, citing no evidence of chronic disability and coded as 5262 (tibia and fibula, impairment of).  At the time of separation, there was radiographic evidence of periostitis of the bilateral shins with clinical evidence of bilateral shin tenderness.  However, the CI had reported resolution of the tibial stress fractures and had refused further evaluation.  The post separation VA C&P examination showed no evidence of chronicity and no chronic effect of the shin splints on the ROM of either the bilateral knees or bilateral ankles.  Based on this information, the tibial stress fracture condition would not be eligible for a permanent disability rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral stress fractures.  

Chronic Ankle Pain.  The STR documented an initial emergency room visit for left foot and ankle pain after taking the physical fitness test in December 2006 (3 months after entry).  The CI had denied trauma or twisting (inversion/ eversion) injury and reported similar episodes during basic combat training.  The examiner documented tenderness without deformity or edema, and prescribed crutches.  Radiologic imaging of the left ankle at that visit documented soft tissue swelling without fracture or dislocation.  At a primary care visit in January 2007 (3 months pre-separation), the CI reported gradual onset of atraumatic left ankle pain and denied locking, popping, swelling and stiffness.  A partial examination was in evidence and the examiner did not specifically document which examination findings pertained to the right or left ankle, or both.  He documented tenderness on ambulation and with palpation of the anterior left ankle; and normal ankle motion.  On the MEB DD Form 2807-1 the CI reported left ankle pain, and the use of ambulatory aids (crutches for 3 months and continued cane use).  On the MEB DD Form 2808 the examiner documented symmetric bilateral ankles with no edema or effusion; no laxity and no ankle (subtalar) pain.  Right ankle dorsiflexion was 18 degrees (normal) and plantar flexion of 44 degrees (normal).  Left ankle dorsiflexion was 14 degrees and plantar flexion was 43 degrees.  

The MEB NARSUM examination was performed on 14 March 2007 (1 month pre-separation).  The CI did not elaborate regarding the ankles.  The examiner documented symmetric bilateral ankles without edema or effusion.  ROM was limited by pain with dorsiflexion of 20 degrees (normal) on the right and 10 degrees on the left; bilateral plantar flexion was 45 degrees (normal).  

At the VA C&P examination performed on 23 April 2008 (12 months post-separation), the CI reported left ankle pain.  The examiner documented that the CI was walking with a limp but did not specify the origin of the limp.  Right and left ankle ROMs were symmetric with normal dorsiflexion and normal plantar flexion, without additional limitations after repetition.  There was pain at the Achilles tendon with plantar flexion of the left ankle.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the “chronic ankle pain” as unfitting, rating 0% coded 5099-5003 (degenerative arthritis) citing “range-of-motion limited by pain,” and rated IAW USAPDA pain policy.  The VA granted service connection for the “Achilles tendonitis, left ankle.”  A 10% was given for the left ankle condition, citing painful motion and analogously coded as 5271-5024 (ankle, limitation of motion; tenosynovitis).  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB “chronic ankle pain” adjudication; although, each joint must be reasonably justified as unfitting for separate disability ratings.  In this case, “bilateral ankle pain” was profiled, implicated by the NARSUM and considered to fail retention standards.  However, the evidence makes clear that the left ankle was associated with more disability than the right ankle in this case.  The commander’s performance statement described functional limitations attributable to “left ankle pain-tendonitis.”  There was repeated documentation of left ankle pain and pain limited motion of the left ankle.  There was no specific documentation concerning the right ankle.  The disparity was such that the question is raised of whether the right ankle was reasonably justified as separately unfitting.  After due deliberation, the Board concluded that the preponderance of evidence showed that there was not a functional impairment from the right ankle condition sufficient to interfere with the CI’s inability to perform her duties; and, accordingly cannot recommend a separate disability rating for it.  The Board considered the evidence for a higher rating.  Given the absence of ankylosis, malunion, and documentation of ‘marked’ limitation of motion, there was no support for a higher than 10% rating.  The ROMs documented in the pre-separation MEB DD Form 2808 and NARSUM could be reasonably characterized as “moderate,” in support of a 10% rating.  However the post-separation VA examination measurements for dorsiflexion (which documented full range-of-motion with pain) would not support a “moderate” rating; this evidence would more appropriately be assigned a 10% rating analogously coded 5271-5024 (ankle, limitation of motion; tenosynovitis) for painful motion (§4.59).  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 left ankle condition, coded analogously coded 5271-5024.  

BOARD FINDINGS:  In the matter of the left hip trochanteric bursitis condition, the Board unanimously recommends a disability rating of 10%, coded 5252-5019 IAW VASRD §4.71a.  In the matter of the bilateral patellofemoral knee conditions, the Board unanimously recommends that each joint be separately unfitting with a disability rating of 10% for the left knee and 10% for the right knee, coded 5260-5024 IAW VASRD §4.71a.  In the matter of the bilateral tibial stress fracture condition, the Board unanimously recommends a disability rating of 0%, coded 5022 IAW VASRD §4.71a.  In the matter of the left Achilles tendonitis condition, the Board unanimously recommends a disability rating of 10%, coded 5271-5024 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Hip Trochanteric Bursitis	5252-5019	10%	
Left Patellofemoral Syndrome	5260-5024	10%	
Right Patellofemoral Syndrome	5260-5024	10%	
Bilateral Tibial Stress Fracture	5022	0%	
Left Achilles Tendonitis	5271-5024	10%	
COMBINED (w/ BLF)	40%	
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140108, 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 XXXXXXXXXXXXXXXXXX, AR20160006653 (PD201400437)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

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 this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:						      					
Enclosure					
CF: 
(  ) DoD PDBR
 ) DVA