RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAMEXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02227
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Trainee, medically separated for “stress fractures of the left knee and right foot,” with a disability rating of 0%.  

CI CONTENTION:  The CI attached a 2-page statement to his application denoting conditions which continue to worsen and negatively impact his daily activities.  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 -  20020731	VARD - 20020819	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures of the Left Knee and Right Foot	5099-5003	0%	Stress Fracture of Left Knee 	5299-5014	10%	STR	
			Stress Fracture Right 1st Toe	5299-5014	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Stress Fractures of the Left Knee and Right Foot.  The PEB combined the left knee and right foot stress fractures under a single disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for the left knee and right foot stress fractures are presented along with separately unfitting recommendations.  If Board members determine by performance based fitness criteria that the condition is reasonably justified as separately unfitting and is separately ratable; IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single Service disability rating from the PEB.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s knee and foot condition began in April 2002 during basic training with no history of direct trauma.  Radiographic evaluations (X-rays and bone scan) revealed patellar tendonitis (Osgood Schlatter disease) of the left knee and stress fractures at the left medial tibial plateau and the right great toe (at the 1st metatarsal phalangeal [MTP] joint).  Despite treatment, the stress fractures of the left knee and right foot 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 “left knee stress fracture and right foot stress fracture” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 16 July 2002 (1 month prior to separation), physical examination showed tenderness over the bilateral medial knees, left tibia, and the right dorsal foot.  

At the MEB NARSUM examination on 18 July 2002 (1 month prior to separation) the CI reported pain with prolonged sitting, squatting, kneeling and with maneuvering stairs.  The examiner documented full range of motion, crepitus, with pain on patellar compression, over the medial tibial plateau, and at the 1st great toe (MTP joint).  The CI’s original VA rating decision dated 19 August 2002 cited no VA Compensation and Pension (C&P) examination as evidence, but listed and referred to his STR.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (arthritis, degenerative), citing “slight/occasional” pain and the U.S. Army Physical Disability Agency Policy/Guidance Memorandum, dated 08 April 2002.  The VA assigned a 10% rating analogously coded 5299-5014 (osteomalacia) for the left knee based on painful motion.  The VA also assigned a 0% rating using the same analogous code for the right first toe, citing no limited or painful motion.  

The Board first considered if the left knee and right foot stress fractures were reasonably justified as separately unfitting (as discussed above).  In this case, the left knee and right foot stress fractures were each profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Members agreed therefore, that the left knee and right foot stress fractures each be reasonably justified as separately unfitting.  

The Board next considered the evidence for rating.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no evidence of moderate knee disability for a higher rating under 5262.  The examinations proximate to separation did not demonstrate the presence of significant ligamentous instability or laxity (5257) for a higher rating.  There was no evidence of a dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) for rating.  However, there was radiographic documentation of a stress fracture of the left knee and Osgood-Schlatter disease, a diagnosis of patellofemoral syndrome, with evidence of painful motion and antalgic gaits in the service treatment record and at the MEB and NARSUM examinations supporting a 10% rating (based on §4.59, §4.40 and §4.45), analogously coded 5299-5261 (analogous code for patellofemoral syndrome).  

There was documentation of foot tenderness; however no documentation of any limited motion of the ankle for a rating under 5271.  There was no evidence of acquired flatfoot or claw foot for coding under 5276 or 5278; and no evidence of bilateral foot weakness for coding under 5277.  There was no evidence of painful motion and no evidence of antalgic gait specifically attributable to the right foot for analogous coding under 5279 (metatarsalgia) or for a moderate rating under 5283 (tarsal or metatarsal bones, malunion of or nonunion of).  However, there was radiographic documentation of a stress fracture and tenderness of the right great toe (at the MTP joint) for a 0% rating analogously coded 5299-5283 (traumatic arthritis; tarsal or metatarsal bones) or 5299-5014 (osteomalacia).  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that both conditions be separately unfitting and recommends a disability rating of 10% for the left knee and 0% for the right foot stress fracture conditions.  

BOARD FINDINGS:  In the matter of the left knee stress fracture condition and IAW VASRD §4.71a, the Board recommends a separately unfit determination with a disability rating of 10% coded 5299-5261.  In the matter of the right foot stress fracture condition and IAW VASRD §4.71a, the Board recommends a separately unfit determination with a disability rating of 0% coded 5299-5283.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Knee Stress Fracture 	5299-5261	10%	
Right 1st Toe (MTP joint) Stress Fracture	5299-5283	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140519, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR2016001 0899 (PD201402227)

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 rating to 10% without 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