RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xxxxxxxxxxxxxxxxxx	CASE:  PD-2014-02301
BRANCH OF SERVICE:  Army	BOARD DATE:  20150602
SEPARATION DATE:  20060921

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Cavalry Scout) medically separated for chronic lower extremity pains involving knees and feet.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “bilateral knee retropatellar pain syndrome” and “chronic bilateral foot pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB. The Informal PEB adjudicated “chronic lower extremity pains involving knees and feet” as unfitting, rated 0%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy. 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:    

IPEB – Dated 20060912	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Extremity Pains Involving Knees and Feet	5099-5003	0%	Left Tibial Plateau Stress Fracture, Shin Splints,
Patellofemoral Pain Syndrome Claimed as Left Knee
Stress Fracture	5299-5260	10%	20070111	
			Right Tibial Plateau Stress Fracture, Shin Splint,
Patellofemoral Pain Syndrome Claimed as Right Knee
Stress Fracture	5299-5260	10%	20070111	
			Left Foot Strain, First Metatarsophalangeal Stress
Fracture Claimed as Left Foot and Ankle Condition	5284	10%	20070111	
			Right Foot Strain Claimed As Right Foot and Ankle
Condition	5284	10%	20070111	
Other x 0 (Not In Scope)	Other x 3 	
RATING:  0%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20070712 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The PEB combined the MEB forwarded conditions of bilateral knee pain and bilateral foot pain as “chronic lower extremity pains” and provided 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.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  Furthermore, IAW VASRD §4.7 (Higher of two evaluations), the Board must then consider separate ratings for PEB bilateral joint adjudications; although, again, separate fitness assessments must justify each Service disability rating.  To that end, the evidence for the bilateral knee and bilateral foot conditions are presented separately; with attendant recommendations regarding fitness, and separate rating if indicated.

Knee conditions.  The narrative summary (NARSUM) notes the CI had an 8-month history of bilateral knee anterior pain that was aggravated by stairs, weight-bearing activity, or prolonged sitting, and relieved by rest.  He denied locking, giving way or swelling of either knee.  Bone scan on 28 September 2005 showed early stress fractures of the inner aspect of both anterior lower legs (medial tibial plateau).  At a physical therapy (PT) evaluation on 11 October 2005 the CI reported equal pain in both knees, rated 9/10.  The exam noted tenderness to palpation (TTP) of both anterior lower legs and patellar tendons and the CI was placed on convalescent (con) leave for three weeks.  A PT follow-up on 13 December 2005 noted no change in symptoms, despite the con leave and PT.  The exam noted a mildly antalgic gait and TTP of the left knee only.  A primary care (PC) visit on 15 February 2006 noted left knee pain and exam showed TTP of the lateral knee areas, left greater than right, but no TTP over the area of the stress fractures.  At a PC visit on 29 March 2006 the CI reported that he hurt his left knee when he jumped over clean floors while mopping and `landed wrong’ on the knee.  The exam noted TTP along the anterior leg and indicated “MRI knee:negative”.  A bone scan on 15 May 2006 noted increased uptake over the outside aspect of the both lower legs (lateral tibial plateau) and was read as “may represent early stress fractures of both areas,” and noted that the earlier (medial) bilateral stress fractures had resolved.

At the MEB examination on 5 June 2006, 4 months before separation, the CI reported bilateral knee pain.  The MEB physical exam, reported for the bilateral knees, indicated TTP of the anterior knees, positive patellar grind tests and full ROM, without instability or effusions.

The VA Compensation and Pension (C&P) General examination on 11 January 2007, 4 months after separation, noted normal strength, sensation, and reflexes of the lower extremities.  At the VA Compensation and Pension (C&P) Bones examination on 24 January 2007, 2 weeks later, the CI reported bilateral knee pain that “comes and goes not necessarily dependent on weight bearing.”  He reported occasional “giving way” of the knees while walking, but no locking or abnormal motion.  He was not using a cane or a crutch, but had a mildly antalgic gait.  The exam noted crepitus and positive patellar grind tests of both knees.  There was TTP of both anterior knees with full ROM and no painful motion noted.

The Board first deliberated if the bilateral knee condition remained reasonably justified as unfitting when separated from the PEB’s combined adjudication.  The bilateral knee condition was considered to fail retention standards; was permanently profiled; and, each knee was implicated by the NARSUM as impairing duty performance.  Members agreed that the functional limitations in evidence justified the conclusion that the bilateral condition was integral to the CI’s inability to perform his MOS; and, accordingly a separate rating is recommended.  Members next considered if each knee remained reasonably unfitting when separated.  In addition to the fitness information noted for the bilateral knees, the Board noted that both the right and left knees were addressed at treatment visits in the STR.  Moreover, since the disability due to only the left or right knee cannot be isolated by the clinical evidence, or discerned from the fitness implications of the bilateral profile limitations, Member consensus was that it would be speculative to conclude that one knee was unfitting, but not the other.  Therefore, Board concluded that each knee was reasonably justified as unfitting and eligible for rating.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the combined bilateral knee and foot conditions 0%, coded 5099-5003 as noted above.  The VA rated the left knee and the right knee, each 10%, both coded 5299-5260 (analogous to limited leg flexion) for pain on use.  The Board noted that repeat bone scans in September 2005 and May 2006 were consistent with stress fractures of both lower legs and there were consistent findings of anterior leg and knee TTP in the STR and at the MEB and C&P exams.  The Board agreed that there was reasonable doubt that the threshold for a minimum 10% rating for chronic knee pain with activity, qualifying as “painful on use” IAW VASRD §4.40 (functional loss) was met for each knee at the time of separation.  The Board reviewed to see if a higher evaluation was achieved with any other applicable code.  There was no limited motion of the leg sufficient to provide a higher rating based on knee ROM alone and there was no evidence of instability, frequent locking with effusion, ankyloses, or femur, tibia or fibula impairment with moderate knee disability, or ankyloses to support higher rating.  The Board noted that 10% rating for each knee could be achieved alternatively coded as 5299-5262, an analogous code for shin splints.  However, the evidence indicates the knee pain was due to patellofemoral pain as well as the healing stress fractures.  Although either coding choice is equally applicable, the pain symptom can only be rated once IAW VASRD §4.14 (Avoidance of pyramiding).  Thus, the Board recommends separate minimum 10% rating of each knee, coded 5299-5260 IAW §4.3 (reasonable doubt) and §4.40.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 and §4.40, the Board recommends a disability rating of 10% each for the left knee and right knee conditions, coded 5299-5260.  

Foot conditions.  The narrative summary (NARSUM) notes the CI had an 8-month history of bilateral foot pain.  Left foot X-rays on 21 September 2005 were normal.  Bone scan on 28  September 2005 showed a stress fracture of the first metatarsal of the left foot near the ankle and moderate symmetrical bilateral stress changes of the mid-foot.  Scant notes that address foot pain in the service treatment record (STR) indicates the CI reported pain of the left foot only.  A single entry in the STR noted bilateral foot pain, but the exam addressed the knees only.  Repeat bone scan on15 May 2006 noted mild uptake in both feet “suggesting stress periosteal reaction,” and also noted a possible focal area of uptake in the left ankle.  

At the MEB examination on 5 June 2006, 4 months before separation, the CI reported bilateral foot pain aggravated by jumping and running, and improved by rest.  The MEB physical exam, reported for the bilateral feet, noted TTP of the foot, just below the ankle and TTP of ankle ligaments.  There was full ROM, without swelling or instability.  The orthopedic examiner indicated that the May 2006 bone scan noted diffuse uptake in both feet that was not consistent with any stress fractures.  

At the VA Compensation and Pension (C&P) General examination on 11 January 2007, 4 months after separation, the examiner noted “on and off has mild pain in left foot,” relieved by over-the-counter medication.  Under the review of systems, the intermittent mild left foot pain was noted, but under right foot symptoms was noted “None”.  The CI did not report any functional impairment due to the foot pain.  The exam noted a normal gait and normal strength, sensation, and reflexes of the LEs.  At the VA C&P Bones examination 2 weeks later, the CI reported bilateral foot pain that “comes and goes not necessarily dependent on weight bearing.”  As noted above the CI was not using a cane or a crutch, but was noted to have a mildly antalgic gait.  There was TTP of the first metatarsal bilaterally (near the toe) and full ankle ROM, with no painful motion.  There was no instability or swelling noted.  No unusual shoe wear was noted.

The Board first deliberated if the evidence supports that the bilateral foot condition remained reasonably justified as unfitting when separated from the PEB’s combined adjudication.  The bilateral foot pain condition was considered to fail retention standards; was permanently profiled; and, each foot was implicated by the NARSUM.  Members agreed that the functional limitations in evidence justified the conclusion that the bilateral foot condition was integral to the CI’s inability to perform his MOS; and, accordingly a separate rating is recommended.  Members next considered if each foot remained reasonably unfitting when separated.  Again, consideration is given to the fitness information for the bilateral foot condition, however, the evidence in the STR indicates the CI sought treatment for left foot pain, but not right.  The bone scan in 2005 noted a stress fracture of the left foot, with nonspecific findings in both feet, and the bone scan in 2006 was interpreted by the orthopedic specialist as not indicating any stress fractures of the feet.  There was no evidence in the STR of right foot pain that could be reasonably assumed to have impacted the CI’s duty performance.  Therefore, Members concluded that there was reasonable support at separation that the left foot condition was unfitting, but not the right foot condition.  

The Board directed its attention to its rating recommendation for the left foot based on the above evidence.  The PEB rated the bilateral foot and knee conditions 0%, as noted above.  The VA rated the left foot condition 10%, coded 5284 (other foot injury).  The evidence supports that the left foot pain was related to a stress fracture of the first metatarsal, which had resolved by the time of the repeat bone scan in May 2006.  The CI reported intermittent, mild left foot pain by the time of the C&P exams, with no documented functional impairment.  Board reviewed rating criteria of 5284, which are subjective, with a threshold rating of 10% for `moderate’ and 20% for `moderately severe’ foot injury.  The Board noted the evidence supports the left foot condition was best characterized as mild corroborated by the CI’s own report, and thus met a 0% rating, coded as 5284.  The Board reviewed to see if a higher rating was achieved with any other applicable code.  There was no evidence of limited ankle motion, painful motion, swelling, instability, flat foot or other deformity, metatarsalgia, malunion or nonunion of a tarsal or metatarsal bone, ankyloses, or other abnormality of the foot or ankle noted in this case.  Additionally, a higher rating could not be recommended according to 5003 criteria for the residual left foot pain related to a stress fracture of a single foot bone, not a major joint or a group of minor joints.  The Board concluded that the disability due to the left foot condition was resolving at separation; was occasional and mild; and, was appropriately rated 0%, coded 5284.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the left foot condition, coded 5284.  

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 chronic lower extremity pains was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic lower extremity pains condition, the Board unanimously recommends a disability rating as follows: an unfitting left knee condition and an unfitting right knee condition, each rated 10%, both coded 5299-5260; and, an unfitting left foot condition rated 0%, coded 5284, all IAW VASRD §4.71a; and, a not unfitting right foot condition.  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	
Chronic Left Knee Pain Condition	5299-5260	10%	
Chronic Right Knee Pain Condition	5299-5260	10%	
Chronic Left Foot Pain Condition	5284	0%	
COMBINED (w/BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140423, w/atchs
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 XXXXXXXXXXXXXXXXX, AR20150018401 (PD201402301)

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 20% 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:

CF: 
(  ) DoD PDBR
(  ) DVA