RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01736
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20070323

SUMMARY OF CASE:  Data extracted from the available evidence of record indicates this covered individual (CI) was an active duty E4, Postal Specialist, medically separated for “left tibial stress fracture,” with a disability rating of 20%.  

CI CONTENTION:  The CI’s contends her stress changes and shin splints in addition to the stress fractures as well as a condition not in scope [lymphedema].  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 – 20070111	VARD - 20080324   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Tibial Stress Fracture	5299-5262	20%	Left Tibia Stress Fracture and shin splints	5299-5262	10%	20070521	
Bilateral Shin Splints	Not Unfitting	Right Shin Splints	5299-5262	0%		
Bilateral Calcaneal Stress Changes		Plantar Fasciitis, Right Foot, with Mild Achilles Tendonitis and Residuals of Calcaneal Stress Fractures	5299-5276	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Tibial Stress Fracture.  The service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM) documented radiographic evaluation of the lower extremities in February 2006 (13 months pre-separation), that showed evidence of bilateral tibial shin splints and a left tibial grade I stress fracture.  At a primary care visit in April 2006 (11 months pre-separation), the examiner documented a normal gait and stance.  Radiographic evaluation (bone scan) in August 2006 (5 months pre-separation), documented 2 “possibly new” left tibial stress fractures, “moderate” bilateral shin splints (“unchanged” from prior), and diffuse stress changes.  At an orthopedic consultation in August 2006, the CI reported 3/10 bilateral lower leg pain worse with any prolonged walking, standing or attempts to run.  She denied any neurovascular symptoms, knee or ankle symptoms, or history of trauma.  The examiner documented a normal gait and stance with no visible swelling.  There was “significant” tenderness over the anterior shin along the entire length of the tibia.  Distal nerve and strength testing was normal.  The examiner diagnosed “possible recurrent” left tibial stress fracture and bilateral “severe” shin splints.  

At the VA Compensation and Pension (C&P) examination performed on 21 May 2007 (2 months post-separation), the CI reported pain in both shins and left ankle with walking for 30 minutes, standing on hard surfaces for 20 minutes, or standing on other surfaces for 45-60 minutes.  Flares occurred daily causing 8/10 pain.  She denied use of assistive devices.  The condition interfered with activities of daily living, such as shopping; and interfered with working, because of the walking restrictions.  The examiner documented no tenderness or effusion.  Radiographs documented no evidence of fracture or arthritic change.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the left tibial stress fracture at 20%, coded analogously as 5299-5262 (tibia and fibula, impairment of).  The VA rated the left tibial stress fracture and shin splints at 10% with the same coding, citing tenderness to palpation, no evidence of painful motion, normal ankle range-of-motion, and slight disability.  

The Board considered the evidence for a higher than 20% rating.  There was no limitations of motion of the foot or ankle for a higher rating under those VASRD codes.  The lower extremity conditions did not cause limitation of flexion or extension of the knee for a higher rating under those codes.  Under the analogous code used by both the VA and the PEB (5299-5262), there was no evidence of moderate knee or ankle disability for a higher rating.  After due deliberation 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 left tibial stress fracture condition.  

Contended conditions: 

Bilateral Shin Splint:  The PEB combined the left and right shin splint and left and right calcaneal stress changes conditions as two Category II conditions.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was appropriate, and there was no need for separate fitness adjudications.  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 evidence for the bilateral shin splints and bilateral calcaneal stress changes conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  The Board first considered if the bilateral shin splint condition, having been de-coupled from the combined PEB adjudication, would render separately unfitting as established above.  

Left Shin Splint:  Through case review, Board members agreed the left shin splint contributed to the disability of the left lower extremity in this case; and, members agreed they were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The Board unanimously recommends that the left shin splint condition be subsumed under the PEB adjudication with the left tibial fracture, without causing a change in rating.  

Right Shin Splint:  The Board’s next charge is to assess the PEB’s determination that the right shin splint condition was not unfitting.  The “right shin splint” was profiled and was judged to fail retention standards by the MEB, but not the PEB.  It was not specifically implicated in the commander’s statement; however, the condition could have contributed to the inability to stand at work longer than 15 minutes.  It was forwarded by the MEB and adjudicated as a Category II condition by the PEB, a condition that “can be unfitting, but are not currently compensable or ratable.”  All were reviewed and considered by the Board.  The Board unanimously agreed that the preponderance of the evidence with regard to the functional impairment of the right shin splint favors its recommendation as an additionally separately unfitting condition for a separate disability.  

According to STR and the MEB narrative summary, the CI initially reported right shin pain at a primary care visit in February 2006 (13 months pre-separation).  There was radiographic evidence (bone scan in February 2006) documented “moderate” bilateral shin splints.  The primary care provider diagnosed “bilateral chronic shin splints” in March 2006.   At a podiatry visit in March 2006, the CI reported anterior shin pain that was more intense on the right.  At a primary care visit in April 2006 (11 months pre-separation), the examiner documented tenderness of the right tibial shaft with a normal gait and diagnosed bilateral shin splints.  At an orthopedic consultation in August 2006 (7 months pre-separation), the CI denied any knee of ankle problems.  The examiner documented significant tenderness over the entire length of the shins with no evidence of edema or pain with muscle compression (compartment syndrome).  All knee and ankle ranges-of-motion in evidence were normal.  A second bone scan performed in August 2006 described the shin splints as “unchanged” from the previous scan, while plain radiographs (X-rays) documented no evidence of stress fractures.  At a VA C&P visit in May 2007 (2 months post-separation), the examiner documented a “slow, antalgic” gait with no limp, and tenderness of the bilateral shins without edema.  

The Board considered the evidence for rating.  There was no documentation of disability or limitation of motion of the knees (5260, 5261, or 5262) or ankles (5271) for a rating higher than 0% under VASRD applicable coding.  There was no radiographic evidence of degenerative arthritis, swelling or satisfactory evidence of painful motion for coding under 5003.  Multiple coding options were considered; however, there was no route to a higher rating that would provide a benefit to the member.  The Board next considered an analogous coding (5022-5003) for periostitis, which was most compatible with the pathology and disability in evidence.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the right shin splint favors its recommendation as an additionally separately unfitting condition for disability rating.  It is appropriately coded analogously as 5022-5003 (periostitis) and meets the VASRD §4.71a criteria for a 0% rating.  

Bilateral Calcaneal (Heel) Stress Changes:  The Board’s first charge for this PEB Category II condition is to assess the fairness of the PEB’s determination that the condition was not unfitting or whether it can be reasonably justified as separately unfitting for rating consideration.  The bilateral calcaneal stress changes were not specifically profiled or implicated in the commander’s statement.  The condition was judged to fail retention standards, by the MEB but not by the PEB.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that the bilateral calcaneal stress changes significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral calcaneal stress changes and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left tibial stress fracture condition and IAW VASRD §4.71a, the Board unanimously no change to the PEB adjudication.  In the matter of the contended left shin splint condition, the Board unanimously recommends this condition be subsumed under the previously unfitting left tibial stress fracture condition, without causing a change to the PEB rating.  In the matter of the contended right shin splint condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 0%, coded 5022-5003 IAW VASRD §4.71a.  In the matter of the contended bilateral calcaneal stress changes, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no overall re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01736.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings