RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02107
BRANCH OF SERVICE:  Army	BOARD DATE: 20150212
SEPARATION DATE:  20020418

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty E-3 (Combat Medic) medically separated for bilateral ankle and wrist pain.  These conditions could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards, so she was issued a permanent U3-L3 profile and referred for a Medical Evaluation Board (MEB).  The ankle and wrist conditions, characterized as “chronic periostitis bilateral lower extremities” and “chronic wrist pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501; no other conditions were submitted by the MEB.  The PEB adjudicated “bilateral lower extremity pain (ankles)…” and “chronic bilateral wrist pain…” as unfitting, each rated 0%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD) for the ankle condition and criteria of the US Army Physical Disability Agency (USAPDA) pain policy for the wrist condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”

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 20011226	VA - (6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral lower extremity pain (ankles)…	5022	0%	Right Ankle Pain	5299-5270	NSC	20021011	
			Left Ankle Pain	5299-5270	NSC		
Chronic Bilateral Wrist Pain	5099-5003	0%	Right Wrist Pain	5299-5215	NSC		
			Left Wrist Pain	5299-5215	NSC		
Other x 0	Other x 11	
Combined Rating:  0%	Rating:  0%	
Derived from VA Rating Decision (VARD) dated 20021114.
ANALYSIS SUMMARY:

Bilateral Lower Extremity Pain (Ankles) Secondary to Periostitis Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the CI experienced lower extremity pain during running while in training (without a specific injury) diagnosed as overuse and periostitis (shin splints and stress reaction on bone scan in the lower extremities).  X-rays demonstrated no fractures, and physical examinations by physical therapy and orthopedic surgery were otherwise negative for other conditions.  The pain improved with avoidance of strenuous training and recurred with resumption of physical training.  At the time of the orthopedic MEB NARSUM on 7 November 2001, the CI reported persistent pain with any running, prolonged standing and brisk walking.  Examination of the lower extremities including the knees and ankles was normal with full range-of-motion (ROM), no instability, no muscle atrophy, and normal strength.  The MEB orthopedic surgeon concluded with diagnosis of chronic periostitis of bilateral lower extremities.  At the VA Compensation and Pension (C&P) examination on 11 October 2002, 6 months after separation, the CI reported persistent aching of her hips and ankles.  On examination, the gait was normal.  There was no joint swelling, tenderness, or limitation of motion.  There was no change with repetitive movement.  X-rays of the lower extremities were unremarkable and a bone scan was noted as unremarkable.  At the time of VA C&P examination on 11 October 2002, the CI reported working full-time as a cashier.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral lower extremity pain (ankles) secondary to periostitis 0% coded 5022 (periostitis) citing normal joint examinations with positive bone scan.  The VA determined the bilateral lower extremity pain was not service-connected as no permanent residual or chronic disability was shown at the time of the after separation VA C&P examination.  The VASRD diagnostic code for periostitis (5022) is rated under code 5003.  There was no limitation of motion of the lower extremity joints to support a rating for limitation of motion and the MEB and VA C&P examinations did not note painful joint motion.  The functional impairment was primarily an inability to perform running in military training.  At the time of the MEB NARSUM, the CI reported pain with prolonged standing; but the proximate post-separation VA C&P examination did not record that impairment and the CI was performing full-time work, which entailed standing.  There were no degenerative changes on X-rays, and according to the VA C&P examination, the bone scan normalized as expected with cessation of strenuous military training.  There were no fractures with non-union or malunion to support consideration of rating under VASRD codes pertaining to fractures.  There were no other conditions identified other than the periostitis due to overuse to support consideration of alternate codes.  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 pain (ankles) secondary to periostitis condition.

Chronic Bilateral Wrist Pain Condition.  According to the MEB NARSUM, the CI experienced gradual onset of wrist pain with performing push-ups, but without any specific injury.  Bone scan and X-rays of the wrists were normal, and physical examinations by physical therapy and orthopedic surgery were otherwise negative for other conditions.  Orthopedic evaluation performed on 4 September 2001 noted there were no wrist complaints at that time.  Orthopedic evaluation on 5 October 2001 noted complaint of chronic bilateral wrist pain with otherwise normal examination, normal X-rays and bone scan.  At the time of the orthopedic MEB NARSUM on 7 November 2001, the CI reported wrist pain with lifting.  Examination of the wrists was normal with full ROM, no swelling, and normal strength without muscle atrophy.  Examination tests for carpal tunnel syndrome and tendonitis were negative.  The MEB orthopedic surgeon concluded with diagnosis of chronic wrist pain without diagnosis of a condition.  At the VA C&P examination on 11 October 2002, 6 months after separation, there was no specific complaint referable to the wrists recorded.  On examination, there was no joint swelling, tenderness, or limitation of motion.  There was no change with repetitive movement.  X-rays of the wrists were unremarkable and a bone scan was noted as unremarkable.  At the time of VA C&P examinations on 11 October 2002, the CI reported working full-time as a cashier.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral wrist pain 0% (coded 5099-5003) with application of the USAPDA pain policy noting normal imaging, and full ROM without laxity.  The VA determined the chronic bilateral wrist pain was not service-connected as no permanent residual or chronic disability was shown at the time of the post separation VA C&P examination.  There was no limitation of motion of the wrist joints to support a rating for limitation of motion and the MEB and VA C&P examinations did not note painful joint motion.  The functional impairment was primarily with lifting however the proximate post separation VA C&P examination did not record impairment and the CI was performing full-time work as a cashier.  There were no abnormalities or degenerative changes on X-rays, and bone scans were normal.  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 chronic bilateral wrist pain 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the bilateral chronic wrist pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the bilateral lower extremity pain (ankles) secondary to periostitis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic bilateral wrist pain 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.

RECOMMENDATION:  The Board, therefore, recommends no re-characterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140425, 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, AR20150010482 (PD201402107)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA