RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01848
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20061030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Aerographer’s Mate, medically separated for “status post stress fractures with residual pain and inability to run,” rated 10% and 10%, respectively [for left and right lower extremities], with a combined disability rating of 20%.

CI CONTENTION:  Her lower extremities condition continues to worsen.  She was not evaluated for fibromyalgia.  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 - 20060619	VARD - 20071107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post (S/P) Stress Fractures (Fx) with Residual Pain and Inability to Run 	5003-5262	20%	Right, S/P healed Pelvic Stress Fx	5299-5255	0%	20061130	
			Right, S/P healed B/L Stress Fxs with Residual Pain & Stress Reaction of Tibia Metaphysis and Shaft	5299-5262	0%		
			Right, S/P Tibial Metaphyseal & Stress Fxs w/ Residual Pain & Stress Reaction	5299-5262	0%		
			Left, S/P healed Pelvic Stress Fx	5299-5255	0%		
			Left, S/P healed B/L Stress Fxs with Residual Pain & Stress Reaction of Tibia Metaphysis and Shaft	5299-5262	0%		
			Left, S/P Tibial Metaphyseal & Stress Fxs w/ Residual Pain & Stress Reaction	5299-5262	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral lower extremity condition began in boot camp, approximately 1 year prior to referral for MEB.  Diagnostic imaging (bone scan) showed multiple stress changes (precursor lesions to stress fractures) in the symphysis pubis and both tibias with the changes in the right tibia bordering on stress fracture (repetitive stress induced fracture) by nuclear medicine criteria.  A repeat bone scan after 6 months showed stress changes that were minimal in the ankles and tarsal bones, and mild in the tibia and left femur, with no areas suggestive of stress fractures.  In the NARSUM, 6 months before separation, the CI reported she had had pain in her lower extremities since boot camp, and had been on light duty her entire time in the Navy.  Pain was exacerbated by prolonged standing, walking, and running.  She had improved somewhat on a program of active rest and closed chain kinetics with pain free activity.  Compiled physical examination findings documented pain with toe walking.  There was tenderness at the bilateral tibia mid shafts and an “elongated area of tingling over her right tibia.”   Bilateral hip range-of-motion (ROM) was full.  The examiner recounted the findings of the initial, and repeat, bone scans.  The diagnosis listed status post stress fractures with residual pain.  In the 30 November 2006 VA Compensation and Pension (C&P) examination the CI complained of a year of constant localized pain below the knees.  Pain was characterized as aching, sharp, and cramping and ranged from 1-7/10 in intensity.  Pain was exacerbated by prolonged standing, walking, running, and activity and relieved by rest and medication.  Her condition did not cause incapacitation and she could function with pain by taking medication.  The physical examination documented a normal gait with no assistive device.  The bilateral distal lower extremity examination revealed right (medial plateau and border) and left (medial metaphysis [transitional zone between end and shaft] and border) tibial tenderness.  The joint examination revealed no edema (excess tissue fluid swelling), effusion (fluid collection), weakness, tenderness, redness, heat, abnormal movement, or guarding of movement.  There was no knee ligamentous laxity.  Bilateral hip ROM was flexion of 125 degrees (125 normal), extension of 30 degrees (20), external rotation of 60 degrees (45), abduction of 45 degrees (45), and adduction of 25 degrees (45).  Bilateral knee ROM was flexion of 140 (140) and extension of 0 (0) degrees.  Bilateral ankle ROM was dorsiflexion of 20 (20) and plantar flexion of 45 (45) degrees.  Lower extremity joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the bone scan and MRI.  The diagnosis listed status post healed bilateral stress fractures with residual pain and stress reactions of tibial metaphyses and shafts.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the right, and a 10% rating for the left, lower extremity (plus bilateral factor = 20% combined) rating under an analogous 5262 code (tibia and fibula, impairment of) citing status post stress fractures with residual pain and inability to run.  The VA assigned a 0% rating for the right, and a 0% rating for the left, lower extremity under an analogous 5262 code based on the VA C&P examination a month after separation.  The VA cited localized residual pain, pain elicited by physical activity and relieved by rest and medication, did not cause incapacitation, bone scan, MRI, normal gait, no edema, no effusion, no weakness, no tenderness, no redness, no heat, no abnormal movement, no guarding of movement, normal ROM, and repetitive ROM not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination.  The ROM values in the proximate exams were normal and did not support a minimum rating under the limitation of thigh extension (5251), thigh flexion (5252),  knee flexion (5260), knee extension (5261), and ankle limited motion (5271) codes.  There was no hip ankylosis (5250), thigh impairment (5253), hip flail joint (5254), or femur fracture nonunion/malunion (5255) for consideration under the respective codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  There was no ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  Board members agreed a 10% rating was justified for each lower leg IAW §4.40 (functional loss) and §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral lower extremity condition.    

BOARD FINDINGS:  In the matter of the bilateral lower extremity condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140515, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 31 May 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						XXXXXXXXXXXXXXXXXXXX	     				  					Assistant General Counsel
						(Manpower & Reserve Affairs)