RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02807
BRANCH OF SERVICE:  ARMY 	BOARD DATE:  20150714
SEPARATION DATE:  20031019

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Trainee) medically separated for bilateral knee and left shin pain.  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 patellofemoral syndrome and left proximal one-third tibial shaft stress fracture” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “bilateral patellofemoral pain syndrome with left proximal one-third tibial shaft stress fracture,…” as unfitting, rated 0%, citing application of the USAPDA Policy/Guidance Memorandum #12, Table of Analogous Codes as well as the 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 20030714	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain Syndrome with Left Proximal One-Third Tibial
Shaft Stress Fracture	5099-5003	
0%
	Right Patellofemoral Syndrome of Knee (Claimed as Bilateral Tibia Stress Fractures)	5099-5020	10%	STR	
			Left patellofemoral Syndrome, with Tibia Stress Fracture of Knee	5099-5020	10%	STR	
Other x 0 (Not In Scope)	Other x 0	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20031024 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  

Bilateral Knee And Left Shin Pain Condition. The earliest note in the service treatment record (STR) dated 4 April 2003 indicated the CI presented with a two week history of bilateral shin pain after doing physical training.  The shin splints were treated with Motrin (a nonsteroidal anti-inflammatory medication) and training limitations.  Further evaluation revealed bilateral tenderness to palpation and edema of the lower extremities, bilateral tibia cortical thickening and right fibula thickening on x-rays, and bilateral tibia stress fractures, left greater than the right on a bone scan.  Physical therapy evaluation and treatment beginning in April 2003 through convalescent leave and follow-up in June 2003 did not resolve the CI’s pain nor was he able to ramp up to running.  On the (DD Form 2807-1), Report of Medical History, dated 6 May 2003, the CI noted he had “painful joints during basic training.  Also had knee trouble in basic training (lots of pain).”  On the Report of Medical Examination (DD Form 2808) the examiner noted genu varum (bow-leggedness) of the lower extremities, but noted the diagnoses as bilateral knee pain/PFS and left tibial stress fracture.

The MEB narrative summary (NARSUM) dated 3 June 2003 was based on the findings of the orthopedic clinic visit of the same date.  It indicated that the CI complained of bilateral knee pain and left shin pain for 2 months, which initially occurred when he fell into a pothole when running.  He had been on convalescent leave and multiple profiles without any relief of his pain.  The CI noted no swelling, but the pain, which was under his kneecap and on the medial lateral aspect of the knees, was brought about ascending and descending stairs and after running on the treadmill after only 5 minutes.  He also had pain on the proximal one-third of the left shin.  On examination the CI had positive patellofemoral (knee area) compression testing with the left greater than the right.  There was no effusion or instability, but he did have positive facet tenderness of the patella (kneecap) on the left.  He was intensely tender to palpation over the proximal one-third of the tibial shaft, but had no ecchymosis (black and blue mark), erythema (redness) or edema and was neurovascularly intact.  A bone scan revealed very intense increased uptake over the left proximal one-third tibial shaft indicating a severe stress fracture.  The diagnosis of bilateral patellofemoral syndrome (PFS) and left proximal one-third tibial shaft stress fracture unrelieved with conservative treatment was made.  At the time of examination, the CI had a slight amount of pain occasionally.  A permanent L3 profile was issued on 11 June 2003 for bilateral knee patellofemoral syndrome/left shin stress fracture with limitations of no running, jumping, marching or ruck.  The commander’s statement dated 11 June 2003 indicated the CI arrived in his company after being diagnosed with a stress fracture of the left shin/PFS of both knees, which limited his participation in any part of One Station Unit Training (OSUT); and since he was unable to participate in any training necessary, he was unable to perform any of his assigned duties.  A VA Compensation and Pension (C&P) examination was not performed and the VA rating of the conditions was based on the MEB examination findings. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using analogous code 5099-5003 (degenerative arthritis) while the VA initially assigned a 20% rating for service-connected vocational rehabilitation purposes using analogous code 5099-5014 (osteomalacia) on 24 July 2003.  Subsequently, on 24 October 2003, the VA assigned a 10% rating using the analogous code 5099-5020 (synovitis) for right patellofemoral syndrome of the knee (claimed as bilateral tibia stress fractures) and a 10% rating using code 5099-5020 for left patellofemoral syndrome of the knee with tibia stress fracture.  The VA Rating Decision (VARD) noted the disability evaluation was based on painful functional impairment of the right knee, per MEB findings of continued full active painful motion, while the left knee was based on painful functional impairment per MEB findings.  The PEB combined the left knee pain and right knee pain conditions under a single disability rating, coded analogously to 5003.  Although VARSD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  If supported under VASRD §4.71a, separate ratings for PEB bilateral joint adjudications may be recommended by the Board.  The Board first considered if bilateral knee pain was reasonably justified as separately unfitting.  Members agreed that the evidence supports that the functional limitations of the bilateral knee pain could be reasonably justified separately and a separate rating is recommended.  In this case, both knees were profiled, considered to fail retention standards, and implicated by the NARSUM and the commander’s statement.  Members agreed that each knee is separately unfitting and that identical coding and ratings could be applicable.  The MEB examination of the knees did not demonstrate a ratable ROM, meniscal removal or dislocation, instability or ankylosis, but did note a positive patellar compression test bilaterally and more so on the left.  Therefore, IAW VASRD §4.59, a rating of 10% using the analogous code 5003 for each knee is reasonable.  Alternatively, for the left knee with the stress fracture, use of code 5262 (tibia and fibula impairment-malunion) offers possibilities of slight knee disability with a 10% rating or a 20% rating with moderate knee 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 right knee patellofemoral syndrome condition and a disability rating of 10% for the left knee patellofemoral syndrome and left shin pain conditions.  

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 Policy/Guidance Memorandum #12, Table of Analogous Codes as well as the USAPDA pain policy, for rating the bilateral patellofemoral syndrome was operant in this case and the condition was adjudicated independently of these policies by the Board.  In the matter of the right patellofemoral syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left patellofemoral syndrome and left shin pain conditions, the Board unanimously recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  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	
Right Patellofemoral Syndrome 	5099-5003	10%	
Left Patellofemoral Syndrome and Left Shin Pain	5299-5262 	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, AR20160002820 (PD201402807)

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 20%
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