RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02197
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Medical Specialist, medically separated for “bilateral lower extremity pain,” with a disability rating of 10%.  

CI CONTENTION:  “I have increased pain in area of hips, the doctors misdiagnosed condition, I still do not know what is wrong!”  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 – 20060511	VARD - 20130607 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Pain	5099-5003	10%	Left SI Joint Stress Fracture (claimed as stress fractures hips, bilateral)	5252	10%	20130604	
Healed Stress Fracture of Left SI Joint and Right Ankle	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Pain.  The service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM) documented multiple bilateral lower extremity stress fractures in October 2005 (during basic training).  Radiographic studies in November 2005 and January 2006 documented normal bilateral hips.  Further imaging in January 2006 (bone scan) documented stress changes of the bilateral knees and right ankle joint, femoral and tibial splints.  There was no surgical indication.  Despite physical therapy and medications, the bilateral lower extremity condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “refractory bilateral lower extremities [sic] pain”] for PEB adjudication.  

At an orthopedic visit in March 2006 (3 months prior to separation), the examiner documented full range-of-motion (ROM) of the knees, tenderness with no localized swelling of the bilateral anterior shins (tibias), and full ROM of the bilateral ankles.  The gait was normal.  On the MEB DD Form 2808, Report of Medical Examination, dated 14 March 2006, the examiner documented “bilateral knee pain since basic training” and “bilateral ankle pain,” with no specific documentation of painful motion during examination.  Right and left knee flexion were to 110 degrees each (normal 140).  Bilateral ankle dorsiflexion was normal.  Bilateral ankle plantar flexion was to 40 degrees (normal 45).  Gait, sensation, strength, and reflexes of the lower extremities were normal.  The commander’s statement (24 March 2006) referenced the left hip and bilateral lower extremity pain as interfering with the performance of duties; however, he did not elaborate further.  At a physical medicine visit in April 2006, the examiner documented full ROM of the bilateral knees without pain, no tenderness on ambulation, and no weakness noted.  There was tenderness of the anterior left kneecap.  Tenderness was noted on examination of the bilateral ankles (right greater than left) and over the right lateral ankle (peroneus brevis tendon).  The ankles were normal in appearance and there was no evidence of instability or pain on motion.  

The MEB NARSUM examination was performed on 6 April 2006 (2 months prior to separation).  The CI reported “unrelenting” pain that was worse with lifting, carrying a heavy load, and walking for more than 10 minutes.  She denied weakness, swelling and stiffness.  The examiner documented a normal gait.  The ROM for the knees and ankles were the same as documented on the DD Form 2808.  There was no STR documentation of ROM of the hips.  There were no VA Compensation and Pension (C&P) examinations in evidence dated within 12 months after separation.  The C&P examination in evidence dated 4 June 2013 (7 years after separation) documented a tender left hip with a flexion of 110 degrees (normal 125) and evidence of painful motion.  The gait was normal.  There were no post-separation examinations of the knees and ankles in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the “bilateral lower extremity pain” as unfitting and rated 10% analogously coded 5099-5003 (degenerative arthritis) IAW the USAPDA Pain Policy.  The PEB agreed with the MEB recommendation for the “healed stress fracture of the left sacroiliac joint and right ankle” as being medically acceptable and did not rate the condition.  There were no VA Rating Decisions in evidence in the 12 months following separation; however, (in 2013) the VA granted service connection for a left sacroiliac joint stress fracture, coded 5252 (thigh, limitation of flexion), and dated to June 2011.  There was no evaluation, service-connection or rating for any other lower extremity condition in evidence.  

Bilateral Knee Pain.  The Board first considered if the bilateral knee condition, should be de-coupled from the combined PEB adjudication, resulting in separately ratable conditions.  “Bilateral lower extremity pain” was profiled, and implicated by the commander’s statement and in the NARSUM.  “Refractory bilateral lower extremities pain” was forwarded by the MEB as not meeting retention standards, and adjudicated as unfitting by the PEB.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties; and, accordingly a separate disability rating is recommended.  The Board next considered whether each knee condition remained separately unfitting, having been de-coupled from the combined PEB adjudication.  The PEB’s DA Form 199 reflected application of the VASRD analogous 5003 code for rating the bilateral knee conditions together.  Although the CI was undergoing an MEB for “bilateral lower extremity pain,” there was no documentation of painful motion, painful gait, and no radiographic evidence of arthritis.  Limitations of motion alone without documentation of painful motion did not provide sufficient grounds for other rating schemes (5260, 5261).  Members debated if 0% was warranted for each knee or if application of §4.40 (functional loss) or §4.59 (painful motion) justified separate 10% ratings.  Each knee condition was evaluated separately in consideration of individual ratings, however the Board concluded that the evidence did not provide sufficient grounds for recommending separate knee disability ratings in this case, and that a bilateral rating of 10%, coded 5299-5003, was a good analogy to both the pathology and disability.  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 bilateral lower extremity condition, coded 5299-5003.  

Left Ankle Pain.  The Board next considered if the left ankle condition, should also be de-coupled from the combined PEB adjudication and evaluated as a separate condition.  “Bilateral lower extremity pain” was profiled, and implicated by the commander’s statement and in the NARSUM.  “Refractory bilateral lower extremities pain” was forwarded by the MEB as not meeting retention standards; and, the right ankle was specifically considered to be not unfitting.  As the right ankle was considered to be not unfit, only the left ankle was included in the PEB combined adjudication as unfitting.  Board members agreed that the evidence reasonably justified that the functional limitations of the left ankle conditions contributed to the CI’s inability to perform her military duties; and, accordingly a separate disability rating is recommended.    

The orthopedic examiner documented full ROM, while the DD Form 2808 and NARSUM examinations both documented normal dorsiflexion and near normal plantar flexion.  “Bilateral ankle pain” was stated by the DD Form 2808/NARSUM examiners with a pain rating described as “slight, constant 24 hours.”  A normal gait was documented; and, painful motion was not specifically stated.  There was no documentation of “moderate” or “marked” limitation of motion (5271) or malunion causing deformity (5273).  There was no evidence of ankle ankylosis in plantar flexion, less than 30 degrees in support of a higher rating.  Unilateral codes (such as 5284) were also considered; however there were no other abnormalities documented that would substantiate a “moderate” level of impairment for a rating under that code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.59 (painful motion) and §4.40 (functional loss), the Board recommended a disability rating of 0% for the left ankle condition, coded 5299-5271 (ankle, limited motion of).  

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that healed left hip (SI joint) stress fracture and right ankle conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  “Bilateral lower extremity pain” was profiled, and implicated by the commander’s statement; and was forwarded by the MEB as meeting retention standards.  The PEB specifically stated that the left hip was not unfitting.  The right ankle, which was not specifically contended, was also considered not unfitting.  There was no ROMs in evidence for the hips and there was no evidence of persistent fracture (reported as “healed”) on radiographic evaluations prior to separation.  There was no performance based evidence from the record that the left hip condition or right ankle 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 left hip and right ankle conditions and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee conditions, the Board unanimously recommends a disability rating of 10%, coded 5299-5003 IAW VASRD §4.71a.  In the matter of the left ankle condition, the Board unanimously recommends a disability rating of 0%, coded 5299-5271 IAW VASRD §4.71a.  In the matter of the contended left hip and right ankle conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Bilateral Knee Pain 	5299-5003	10%	
Left Ankle Pain	5299-5271	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140501, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
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 XXXXXXXXXXXXXXXXXX AR20160011982 (PD201402197)

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, accept the Board’s recommendation to modify the individual’s disability description without modification of the combined rating or re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA