RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-02756	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20150512
SEPARATION DATE:  20050826		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Basic Trainee) medically separated for bilateral lower extremity pain and shortness of breath.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3 L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “bilateral medial tibial plateau stress fractures,” “bilateral ankle/foot chronic pain/ stress reactions” and “exercise-induced asthma,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (migraine headaches) for PEB adjudication.  The Informal PEB adjudicated “chronic bilateral lower extremity pains” and “shortness of breath with exercise with onset prior to entry (EPTS)” as unfitting, rated 0% and not rated (EPTS), respectively.  The remaining condition (migraine headache) was determined to be not unfitting.  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 20050826	VA - (~7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Extremity Pains	5099-5022	0%	Residuals, Stress Fracture Left Tibia	5262	10%	20060425	
			Residuals, Stress Fracture  Right Tibia	5262	10%	20060425	
			Residuals, Left Ankle Sprain	5271	0%	20060425	
			Residuals, Right Ankle Sprain	5271	0%	20060425	
			Residuals, Stress Fracture Left Mid-Foot	5299-5284	0%	20060425	
			Residuals, Stress Fracture, Right Mid-Foot	5299-5284	0%	20060425	
Shortness of Breath	6602	---%	No VA Entry	
Migraine Headaches	Not Unfitting	No VA Entry	
Other x 0  (Not in Scope)	Other x 0 (Not in Scope)	
Combined:  0%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20060508 (most proximate to date of separation [DOS]). 

ANALYSIS SUMMARY:  The PEB combined the chronic bilateral lower extremity pain conditions under a single disability rating, coded analogously to 5099-5022.  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 disability 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 each condition is presented separately along with separately unfitting recommendations.  If Board members determine by performance based fitness criteria that the condition is reasonable justified as separately unfitting and is separately ratable; IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  

Bilateral Medial Tibial Plateau Stress Fractures.  At an emergency room visit dated 7 April 2005, the CI reported left knee pain after a fall a week earlier.  The examiner documented no swelling, no deformity, and “decreased” range-of-motion (ROM).  Radiographs of the left knee were normal.  At a follow-up visit dated 12 April 2005, the CI was using crutches and had a profile.  The examiner documented the right knee as having full ROM with tenderness to palpation of the medial condyle and no crepitus.  At a visit dated 20 April 2005, the CI reported worsening bilateral knee pain with swelling.  The examiner documented full ROM with pain, tenderness to palpation of both inner aspects of the knees without crepitus.  There was no edema, erythema, bruising, effusion or deformity and muscular strength was 5/5 (normal is 5/5).  The patella was normal.  The knees were noted to have “laxity on the left greater than the right with good end point,” and no evidence of instability (negative anterior/ posterior drawer, negative Lachman’s and McMurrays’, and negative varus stress).  The examiner diagnosed “stress reaction of the bilateral knees,” ordered a bone scan, and recommended continued crutch ambulation for an additional week.  In 26 April 2005, the CI reported 8/10 (10/10 is severe pain) pain of both knees.  The examiner documented that the bone scan was positive for stress fractures and stress reaction changes in the knees (medial femoral condyles and medial tibal plateaus [MTPs] bilaterally), both ankles (distal tibiae), and feet (metatarsals).  At a visit with the physical therapist dated 27 April 2005, the CI reported rapid onset bilateral knee pain during her Army physical fitness test (APFT) run.  The pain worsened with walking, resulted in 3 days at the infirmary, and had not improved after 2 weeks of using crutches.  The examiner documented an antalgic gait bilaterally, full bilateral knee ROM, tenderness on palpation of the MTPs of both knees, and pain during partial squat and other maneuvers.  The examiner recommended 30 days of convalescent leave during which she could “progress off crutches and increase walking tolerance… swim and bike for cardiovascular exercise.”  Radiographs dated 27 April 2005 and 3 June 2005 showed no evidence of fractures or bony lesions of either leg.  At a clinic visit with physical therapy dated 3 June 2005, the CI reported no pain in the left knee, and continued 6/10 pain of the right medial knee and ankle; that increased to 7/10 with walking.  The examiner documented a right sided antalgic gait with tenderness on palpation of the right inner knee, ankle with increased pain while partially squatting.  The examiner opined a “poor prognosis due to motivation and high pain levels” and to resume use of crutches until normal gait achieved.  At the MEB examination dated 10 June 2005, the CI reported that her “knees are giving [her] a lot of pain.”  The MEB physical examiner noted bilateral tenderness at the knees, right greater than left, without instability.  The narrative summary (NARSUM) dated 22 July 2005 documented full bilateral knee ROM and localized tenderness of the inner knees without swelling, ecchymosis, effusion, or instability; and 5/5 strength of all muscle groups.  

At the VA Compensation and Pension (C&P) examination performed seven months after separation, the CI reported constant knee pain, right greater than left; edema and crepitus; and giving way of the right knee only.  She denied weakness, stiffness, locking or fatigability of her knees.  She reported difficulty standing more than 30 minutes given her bilateral knee and ankle conditions.  She denied use of ambulatory aids and denied flare ups and any adverse effects of her lower extremity conditions on her occupational duties or activities of daily living.  The examiner documented a right knee ROM of 0-140 degrees (normal 0-140 degrees), a left knee ROM of 0-150 degrees; and painful motion of both knees with repetitive testing against resistance only.  There was no laxity or instability of either knee.  There was a normal gait, normal strength, and no evidence of edema, effusion, weakness, tenderness, redness, guarding, or abnormal movement of the knees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated “chronic bilateral lower extremity pains” as unfitting, rated 0% IAW VASRD and coded analogously as 5099-5022 (periostitis).  The VA rated the multi-joint pain condition at 10% each for “residuals, stress fracture left tibia” and “residuals, stress fracture right tibia” coded as 5262 (tibia, impairment of: with slight ankle disability); rated 0% for the left and right ankle sprains, coded as 5271 (ankle, limitation of motion); and rated 0% each for the “residuals, stress fracture, right and left mid-feet”, coded 5299-5284 (foot injuries, other).  

The Board first considered if the bilateral MTP stress fractures, having been de-coupled from the combined PEB adjudication, were reasonably justified as separately unfitting.  The lower extremity conditions were profiled as bilateral, implicated in the NARSUM, and designated as failing to meet retention standards.  Members agreed that the functional limitations in evidence justified the conclusion that the conditions were integral to the CI’s inability to perform the duties of her MOS and that each knee could be reasonably justified as separately unfitting and a separate Service rating are recommended.  

The Board then considered the rating recommendation.  The VASRD §4.71a specifies for 5003 that “satisfactory evidence of painful motion” constitutes limitation of motion; and, that a 10% rating can be granted “for each such major joint or group of minor joints affected by limitation of motion.”  There was radiographic evidence of bilateral knee (MTP) stress fractures, and there was documentation of painful motion (abnormal gait, painful squat) that required use of assistive devices prior to separation that would warrant a rating of 10% for each knee coded analogously as 5099-5003/5022 or 5262 (tibia, impairment of: with slight knee disability).  There was scant documentation of any compensable limited ROM of either knee, and no swelling, effusion, edema, instability, or laxity to warrant meniscal coding or a higher rating under other knee specific VASRD codes.  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 right and 10% for the left tibial plateau stress fractures.  

Right Ankle Stress Reaction/Sprain.  At an acute visit dated 16 March 2005, the CI reported having fallen on a rock and injuring her right ankle.  The examiner documented an antalgic gait, tenderness of the right ankle at the anterior talofibular ligament with mild swelling and no instability.  She was diagnosed with a right ankle sprain/contusion, given anti-inflammatory medications, muscle relaxants, a brace, crutches, and activity modification.  At a follow up dated 22 March 2005, the CI reported taking anti-inflammatory medications and being “much better.”  The examiner documented a normal gait and recommended discontinuation of the crutches and extension of the profile for another 10 days before returning to duty.  At visits in April 2005, the CI reported 7/10 pain of the right ankle.  The ankle and foot pain were not controlled by rest or medications.  The examiner documented that the bone scan was positive for stress fractures and stress reaction changes in the right ankle.  At a visit with the physical therapist dated 27 April 2005, the CI reported rapid onset right ankle pain during her APFT run.  The pain worsened with walking, resulted in 3 days at the infirmary, and had not improved after two weeks of using crutches.  The examiner documented an antalgic gait bilaterally and pain during partial squat and other maneuvers.  The examiner recommended 30 days of convalescent leave during which she could “progress off crutches and increase walking tolerance… swim and bike for cardiovascular exercise.”  Radiographs dated 27 April 2005 and 3 June 2005 showed no evidence of fractures or bony lesions of either leg.  At a clinic visit with physical therapy dated 03 June 2005, the CI reported continued 6/10 pain of the right ankle; that increased to 7/10 with walking.  The examiner documented a right sided antalgic gait with tenderness on palpation of the distal right leg and anterior ankle with increased pain while partially squatting.  

At the NARSUM examination, the CI reported continued bilateral 4/10 ankle pain that increased to 8/10 with any prolonged walking or standing.  The examiner documented full ROM without tenderness, swelling or bruising of the ankles and opined that she was “expected to heal and totally recover from the stress fractures.”  At the VA C&P examination, the CI denied weakness, stiffness, locking or fatigability of her ankles.  She reported that the right ankle gives way and pops and was more painful than the left ankle.  She used a right ankle brace “most days.”  Right ankle dorsiflexion was 0-20 degrees (normal) and plantar flexion was 0-45 degrees (normal) without painful motion at baseline or after repetition.  There was a normal gait, normal strength, and no evidence of edema, effusion, weakness, tenderness, redness, guarding, or abnormal movement of the right ankle.  

The Board directed attention to its rating recommendation based on the above evidence.  The VA rated 0% each for the right ankle sprain, coded as 5271 (ankle, limitation of motion).  The Board considered if the right ankle condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  Although the lower extremity conditions were combined and profiled as bilateral, implicated in the NARSUM and designated as failing to meet retention standards, neither the STR nor physical findings documented by the MEB or VA examiners supported that the functional limitation of the right ankle condition interfered with the CI’s performance of duties at the time of separation.  After due deliberation in consideration of the totality of the evidence, members agreed that the right ankle condition was not reasonably justified as separately unfitting; and no additional Service disability rating can be recommended.  

Left Ankle Stress Reaction/Sprain.  At visits in April 2005, the CI reported pain of the foot (unclear if left vs right).  The ankle pain was not controlled by rest or medications.  The examiner referenced the bone scan dated 26 April 2005 stating that it was positive for stress fractures and stress reaction changes in the left ankle.  At the VA C&P examination, the CI denied weakness, stiffness, locking or fatigability of her ankles.  She reported that the right ankle was more painful than the left ankle.  Left ankle dorsiflexion was 0-20 degrees (normal) and plantar flexion was 0-45 degrees (normal) without painful motion at baseline or after repetition.  There was a normal gait, normal strength, and no evidence of edema, effusion, weakness, tenderness, redness, guarding, or abnormal movement of the left ankle.  There was no callus formation, skin breakdown, or unusual shoe wear pattern noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The VA rated 0% each for the left ankle sprain, coded as 5271 (ankle, limitation of motion).  The Board considered if the left ankle condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  Although the lower extremity conditions were combined and profiled as bilateral, implicated in the NARSUM and designated as failing to meet retention standards, neither the STR nor physical findings documented by the MEB or VA examiners supported that the functional limitation of the left ankle condition interfered with the CI’s performance of duties at the time of separation.  After due deliberation in consideration of the totality of the evidence, members agreed that the left ankle condition was not reasonably justified as separately unfitting; and no additional disability rating can be recommended.  

Bilateral Mid Foot Stress Reactions.  At visits in April 2005, the CI reported 7/10 pain of the feet.  The foot pain was not controlled by rest or medications.  The examiner referenced the bone scan that was positive for stress reaction changes in both feet (metatarsals).  At a clinic visit with physical therapy dated 3 June 2005, the examiner documented a right sided antalgic gait with increased pain while partially squatting.  At the VA C&P examination, the CI reported that her shoe inserts were excellent at preventing her foot symptoms and denied any foot symptoms bilaterally.  There was normal ROM of both feet and no abnormalities noted.  There was a normal gait, normal strength, and no evidence of edema, effusion, weakness, tenderness, redness, guarding, or abnormal movement of the feet.  There was no callus formation, skin breakdown, or unusual shoe wear pattern noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The VA rated 0% each for the “residuals, stress fracture, right and left mid-feet”, coded 5299-5284 (foot injuries, other).  The Board considered if the bilateral foot conditions, having been de-coupled from the combined PEB adjudication, were reasonably justified as separately unfitting.  Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  The bilateral foot conditions were implicated in the NARSUM and designated as failing to meet retention standards, however they were not specifically profiled.  The Board could not find evidence in the STR that documented any significant interference of the bilateral foot conditions with the performance of duties at the time of separation.  After due deliberation, members concluded that the bilateral foot conditions were not integral to the CI’s inability to perform her MOS; could not reasonably be justified as separately unfitting; and, accordingly cannot recommend a separate rating for it.  

Shortness of Breath.  At an acute care visit dated 22 April 2005 the CI reported difficulty breathing with increased activity, shortness of breath (SOB), and wheezing when running for 8 weeks.  The examiner documented no wheezing on examination, diagnosed a “viral upper respiratory infection,” and prescribed over the counter medications.  While at home on convalescent leave in May 2005, the CI denied asthma symptoms at rest, but continued to notice chest tightness, SOB, and wheezing only with exercise.  She also reported coughing at morning 2 to 3 times weekly.  At a clinic visit dated 1 June 2005, the CI stated having day and night symptoms of SOB, chest tightness, wheezing, and coughing spells, which began within 2-3 minutes of increased activity and resolved 15 minutes after stopping.  The CI admitted to having these symptoms prior to service entry; however she had used her mother’s inhaler, and never sought treatment.  The examiner documented a normal respiratory examination.  A Broncho-challenge performed on 9 June 2005 was indicative of exercise induced asthma (24% decline in forced expiratory volume).  The NARSUM documented that during basic training in March 2005, her pre- military respiratory symptoms were aggravated until she was profiled for limited duty and exercise activity.  The examiner documented a normal examination, stated that the Broncho-challenge was positive for exercise induced asthma, and prescribed a bronchodilator.  At the VA C&P examination, the CI did not mention the exercise induced asthma and did not list bronchodilators in her medication profile.  

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB adjudicated the shortness of breath as unfitting, EPTS with no permanent service aggravation, and rated ---%; coded 6602 (asthma, bronchial).  The VA did not evaluate this condition and did not give a rating.  The Board noted that there was no diagnosis of exercise induced asthma prior to Service entry; however there was STR documentation that the CI had respiratory symptoms with exercise prior to Service entry.  The NARSUM examiner documented that the CI had shortness of breath prior to Service entry; added “exercise induced asthma” to the final permanent profile dated 22 July 2005; and stated that it failed to meet retention standards.  The Board agreed that the evidence supported the PEB determination that the condition existed prior to service and was not permanently service aggravated.  After due deliberation in consideration of the preponderance of the evidence, members agreed that there was insufficient cause to recommend a change in the PEB’s determination that the shortness of breath condition was unfitting, existed prior to service, and was not permanently aggravated by service; therefore, this condition could not be recommended for additional disability rating.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the migraines were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

Migraines.  A discharge summary dated 26 April 2000 documented a hospital admission for migraine therapy when the CI was 15 years old.  The examiner stated that she had a known history of migraines and responded well to medications.  The STR was silent for migraines for 5 years.  An emergency room note dated 28 March 2005 referenced three visits over a 3-day period for persistent headache symptoms.  There was no documentation of physician prescribed bed rest.  An internal medicine consultation dated 31 March 2005 documented that the CI had migraines every other month since age 13 years old that were better with sleep and worsened while wearing a helmet.  She was treated with pain medications and released without limitations.  At the VA C&P examination, the CI reported being diagnosed with migraines in 1997; that they occurred once a month or every other month, lasted a full day; and were controlled by medications.  

All evidence was reviewed by the action officer and considered by the Board.  The migraine condition was not profiled and was not judged to fail retention standards.  There was no performance based evidence from the record that the condition 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 migraine condition and so no additional disability rating is recommended.  

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the bilateral medial tibial plateau stress fractures, the Board unanimously agrees that each knee was separately unfitting and unanimously recommends a disability rating of 10% each knee, coded 5099-5022 IAW VASRD §4.71a.  In the matter of the bilateral ankle and feet stress reactions, the Board unanimously agrees that they were not separately unfitting and cannot be recommended for additional disability ratings.  In the matter of the contended migraine condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Left Medial Tibial Plateau Stress Fracture	5099-5022	10%	
Right Medial Tibial Plateau Stress Fracture	5099-5022	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140610, 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 XXXXXXXXXXXXXXXXXX, AR20150018836 (PD201402756)

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