RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01684
BRANCH OF SERVICE:  Army	BOARD DATE:  20150122
Separation Date:  20050208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (11C/Infantry Mortar Man) medically separated for chronic pain left leg.  The condition 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 pain left leg condition, characterized as “chronic left leg pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The informal PEB adjudicated “chronic pain left leg” as unfitting, rated 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”  [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 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 IPEB – Dated 20041129	VA - (6 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Leg	5099-5003	10%	Periostitis with Left Leg Traction (claimed as shin splints and left leg pain)	5022	0%	20040831	
			Left Knee Strain	5024-5261	10%		
			Left Foot S/P Third Metatarsal Stress Fracture	5299-5283	0%		
Other x 0	Other x 0	
Rating:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20050314 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Chronic Pain Left Leg Condition.  The evidence supports that during initial military training the CI suffered a sprained left knee and ankle along with a stress fracture of his left foot.  Plain film X-rays of the left knee and ankle were normal while a bone scan of the left foot confirmed the stress fracture.  He was treated with physical therapy, non-steroidal anti-inflammatory drugs and several periods of convalescent leave.  After approximately 4 months of relative rest, the CI continued with intermittent left foot pain in spite of a normal bone scan and X-rays of the left foot.  Additionally, during this same period of time, he developed shin splints of the left lower leg.  A bone scan was performed and was consistent with early bilateral shin splints.  Six months prior to separation, X-rays of the left knee, ankle, and foot were normal.  The CI could not resume training and he was entered into the disability evaluation system.  The VA Compensation and Pension (C&P) exam performed approximately 6 months prior to separation documented that the CI had constant left knee pain.  He was functionally impaired in that he could not run or walk for long periods of time.  The VA C&P physical exam revealed an antalgic gait and normal left tibia and fibula.  The left knee flexion was 120 degrees (140 degrees is normal) and -10 degrees extension, crepitus was present.  There was no instability or Deluca criteria (repetitive motion testing) present.  Examination of the left ankle was normal while the left foot had some tenderness without any limitation of standing or walking.  Plain film X-rays of the left knee, shin, and foot were normal.  The MEB narrative summary (NARSUM) exam accomplished approximately 4 months prior to separation documented that the CI had chronic persistent leg pain in which the knee would pop, and give out at times.  The NARSUM physical exam showed an antalgic gait with left knee findings of tenderness to palpation without instability.  The flexion was 135 degrees with normal extension.  There was tenderness to palpation of the left shin and left ankle.  The ankle range-of-motion (ROM) was 8 degrees of dorsiflexion (20 degrees is normal) and 30 degrees of plantar flexion (45 degrees is normal).  The NARSUM summarized the radiographic findings mentioned above.  The NARSUM examiner made the following statement concerning the CI’s functional status, “ADL (activity of daily living) also impacted due to inability to ambulate normally with weight bearing left leg.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic pain left leg condition by applying VASRD code 5099 analogous to 5003 (degenerative arthritis) and rated it 10% with cited application of the USAPDA pain policy.  The VA coded the left leg under three separate disability codes: left knee strain under analogous code 5024-5261 at 10%; left foot pain under analogous code 5299-5283 at 0%; and periostitis with left leg traction (claimed as shin splints and left leg pain) under code 5022, (periostitis), and rated it 0% based on no limitation of ankle motion at the time of the C&P examination and did not apply a code for an ankle condition.  The evidence supports that the CI had persistent left lower extremity pain over the year prior to separation.  While he did have injuries to the knee, ankle, and foot, all radiographic studies of those areas were normal 5 months prior to separation.  After review of the evidence, Board members agreed that the CI’s left foot stress fracture had resolved prior to separation.  The remaining left leg pain was a combination of knee, shin, and ankle pain, which could not be attributed to one condition or joint without considerable speculation.  The NARSUM did document left ankle ROM measurements that are compensable under the ankle specific VASRD code 5271 (limited ankle motion) at a maximum of 20%.  The Board considered code 5262 (impairment of the tibia and fibula) and members agree that it represented to best coding option upon which to base its rating recommendation.  This code has three rating options based on the degree of knee or ankle disability:  10% (slight disability), 20% (moderate disability), and 30% (marked disability).  Because the CI had daily pain and an antalgic gait with some impact on his activities of daily living, Board members agree that this was best characterized as a moderate disability, affording a 20% rating as most appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic pain left leg condition, coded 5299-5262 IAW VASRD §4.71a.
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 (635-40) for rating the chronic pain left leg condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic pain left leg condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5262 IAW VASRD §4.71a.

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	
Chronic Pain Left Leg	5299-5262	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140410, 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 XXXXXXXXXXXXXXX, AR20150010450 (PD201401684)

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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA