RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02015
BRANCH OF SERVICE:  Army	BOARD DATE:  20150319
SEPARATION DATE:  20020530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Army Diver) medically separated for a lower extremity stress condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards or but was authorized to perform an alternate physical fitness test. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “severe stress reactions versus stress fracture of the tibial shaft on the left side” and “severe stress reaction of the right tibial which is moderately symptomatic,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “bilateral lower extremity stress reactions without evidence of fracture” as unfitting, rated 0%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I am still in college, pursuing a new career after multiple attempts at my previous two career avenues of structural welder and OTR Truck driver being unable to perform either task due to my injuries in both legs: daily irritation, inability to run, jump, lift over 50 lbs” [sic] “no service connection could be granted” for the claim of: “Lumbar strain (also claimed as thorasic [sic] secondary to bilateral stress fractures.” This decision should be reconsidered in conjuction with current diagnosis of arthritis in spine and shoulder.

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:

IPEB – Dated 20020430	VA* - (~12 yrs. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Stress Reaction w/o Evidence of Fractures	5099-5022	0%	Medial Stress Syndrome Tibial Shaft…Right Side	5262	0%	20140319	
			Medial Stress Syndrome Tibial Shaft…Left Side	5262	0%	20140319	
Other x 0 (Not In Scope)	Other x 1 (Not in Scope)	
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20140328 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The PEB combined bilateral lower extremity stress reactions as a single unfitting condition coded analogously to 5022, which is rated IAW code 5003.  The Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting.  Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Bilateral Lower Extremity Stress Reaction w/o Evidence of Fractures Condition.  The earliest note in the service treatment record is dated 7 December 2001 at which time the CI presented to the podiatry service with a complaint of bilateral ankle pain with swelling for 3 days during the first week of Basic Training.  Examination revealed tenderness to touch of both ankles and legs with edema.  X-ray studies on 7 December 2001 of the ankles and feet revealed normal feet with a bipartite medial sesamoid bone (located on the underside of the base of the big toe) of the left first metatarsal phalangeal joint and accessory cuboid bone on the left and no other significant abnormalities or signs for stress fracture injury and no fractures or bony lesion of the tibia or fibula of either leg.  Follow-up X-rays of the right leg were normal on 4 January 2002.  Physical therapy was carried out for 5 weeks with persistence of pain and tenderness to palpation and pitting edema noted on 12 February 2002 of both mid tibias (shins) more on the left.  Follow-up X-rays of the both anterior tibia (legs) on 12 February 2002 were normal.  A bone scan of both tibia on 5 March 2002 revealed diffuse uptake bilaterally, a stress fracture of the left medial (inner) femoral condyle (back upper part of the knee joint) and severe stress changes versus an early stress fracture of the mid to distal (lower) left tibia.  At a follow-up physical therapy examination on 26 March 2002, there was still tenderness to palpation on both distal tibias, although minimal on the right.

The MEB narrative summary dated 28 March 2002 indicated the CI noted severe bilateral leg pain (left great than right) in early December 2001, which was exacerbated by running, jumping, and twisting activities as well as prolonged standing and marching.  In the office the pain was 3/10 (10 being the worst pain) and when running it was 8/10.  He had been in Physical Training and Rehabilitation Program for 2 months, but still had pain sufficient enough to preclude his return to basic training.  Physical examination revealed tenderness to palpation about the medial (inner) aspect of the left lower extremity at the junction of the middle and distal thirds, while the right lower extremity was minimally tender to palpation throughout.  No skin changes were present on either leg.  The X-rays of both legs were reviewed and some cortical thickening was noted on the left at the junction of the middle and distal thirds with no obvious stress fracture; and, review of the bone scan was consistent with a severe stress reaction versus a stress fracture of the left tibia as well as severe stress reactions in the right tibia.  Modification of activities failed to ameliorate the pain of the left leg, which was moderately to severely symptomatic and the right leg, which was moderately symptomatic.  A permanent P3 profile was issued on 28 March 2002 for severe stress reaction of both legs with limitations of no running, jumping, marching, physical fitness testing, and wearing a backpack.  No commander’s statement was available for review.  At the MEB examination dated 2 April 2002, the CI reported stress fractures/stress reactions in both tibia, left knee and right metatarsal while training.  The MEB physical examination noted increased tenderness in both tibia and the left knee.  The temporally remote (almost 11 years and 10 months after separation) VA Compensation and Pension examination was reviewed; however, it offered very limited or no probative after separation evidence of any significant value, but indicated the bilateral leg pain became better for about one to two years then he began to notice increase after jumping, trying to run or carry a weight over about 75 pounds.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5022 (Periostitis) for bilateral lower extremity stress reactions without evidence of fracture on X-ray.  The VA, almost 12 years after separation, assigned a 0% rating using code 5262 (Tibia and fibula impairment) for the stress syndrome of the left tibial shaft and a 0% rating using code 5262 (Impairment tibia and fibula) for the stress syndrome of the right tibial shaft.  The Board first considered whether the left lower extremity stress reaction, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to complete training or perform his MOS; and, accordingly a separate rating is recommended.  The Board then considered whether the right lower extremity stress reaction, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to complete training or perform his MOS; and, accordingly a separate rating is recommended.  Code 5262 is appropriate to address the CI’s clinical and imaging findings.  The left tibia had findings of severe stress changes versus early stress fracture at mid to distal tibia, which brings the anatomical changes on bone scan imaging closely congruent to code 5262 for a 10% rating since the knee joint involvement is supported by the finding of a stress fracture at the femoral condyle and the ankle is represented by changes at the distal tibia.  On the other hand, the stress changes of the right tibia do not truly represent a malunion.  Therefore, use of an analogous code 5299-5262 addresses the anatomical locus of the stress changes; however, in the absence of slight knee or ankle disability the appropriate rating is 0% for the right tibia; and no route to a higher rating could be found.  The Board also discussed the use of the analogous code 5022, which is rated according to limitation of motion using code 5003.  However, there was no limitation of motion of either the knee or ankle joints, and there were not actual X-ray changes, but instead there were the bone scan imaging changes.  Even if the bone scan imaging changes were used in lieu of the X-rays, a 10% rating is the maximum that can be assigned for two or more major joints in the absence of incapacitating exacerbations with the use of code 5003.  However, Note (2) of code 5003 indicated that rating conditions under diagnostic codes 5013 to 5024 cannot be utilized with code 5003; and, therefore, code 5022 is precluded from use.  Alternatively, the Board considered using analogous code 5099-5003 for the imaging rating in the absence of a limitation of motion, but the Board members felt an  individual rating for each tibia was more appropriate and on point.  Muscle codes were discussed, but could not provide a route to a higher rating since there was no evidence to support the use of any muscle code.  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 lower extremity stress reaction/stress fracture condition and recommends a disability rating of 0% for the right lower extremity stress reaction condition.

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.  In the matter of the left leg stress reaction/stress fracture condition, the Board unanimously recommends a disability rating of 10%, coded 5262 IAW VASRD §4.71a.  In the matter of the right leg stress reaction condition, the Board unanimously recommends a disability rating of 0%, coded 5299-5262 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:

CONDITION	VASRD CODE	RATING	
Left Leg Stress Reaction/Stress Fracture	5262	10%	
Right Leg Stress Reaction	5299-5262	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201w/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, AR20150013701 (PD201402015)

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 10% 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