RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03160
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030519

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Light Wheeled Vehicle Mechanic) medically separated for chronic bilateral lower leg pain rated at 0%.

CI CONTENTION:  “Please consider all conditions” 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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 20030219	VA* - (~1 Mo. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Leg Pain	5099-5003	0%	Left Tibial Stress Reaction with Achilles Tendinitis	5262	10%	20030602	
			Right Tibial Stress Reaction with Achilles Tendinitis	5262	10%	20030602	
Diffuse Muscle and Joint Pain	Not Unfitting	Myopathy, Polymyositis and Muscle and Joint Pain	5299-5025	NSC	20030602	
Low TSH	Not Unfitting	Low TSH	7999-7903	NSC	20030602	
High Blood Pressure	Not Unfitting	Hypertension	7101	10%	20030602	
Asthma	Not Unfitting	Intermittent Asthma	6602	10%	20030602	
Leg Pain	Not Unfitting	No VA Placement	
Other x 0 (Not In Scope)	Other x 4 	
RATING:  0%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20031218 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The PEB combined the left and right lower leg pain conditions 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.  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 Service 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.

Bilateral Tibial Stress Fracture Condition.  The service treatment record (STR) documents that the CI complained of bilateral leg pain following a ruck march.  A bone scan showed bilateral tibial stress fractures (fatigue-induced fracture caused by repetitive stress).  Bilateral leg X-rays were unremarkable.  Weight bearing ankle X-rays were unremarkable except for bilateral pes planus (flatfeet).  The narrative summary (NARSUM) documented that bilateral leg and ankle pain began two years prior, with no antecedent trauma.  The CI reported the pain started after a 3-mile ruck march.  The chronic pain was located in the anterior aspect of his legs and at one point extended up onto his thighs.  Symptoms were exacerbated by activity (prolonged standing, walking, running, jumping, rucking and lifting heavy objects) and relieved with rest.  The CI had no significant improvement with nonsteroidal anti-inflammatory drugs (NSAIDs), a heavily-restricted profile, and a change in MOS.  On exam, the CI did not report any pain with heel raises or walking on the heels.  The bilateral lower extremity exam revealed normal skin and hair growth pattern.  There was no muscular atrophy or atrophy of hair.  There was bilateral tenderness of the proximal 1/3 of the lateral tibias, distal 1/3 of the medial tibias, and medial malleolar anterior-inferior joint lines.  There was bilateral pain with bone percussion of the distal 1/3 of the anterior-medial tibias.  Bilateral knee range-of-motion (ROM) was flexion (140 normal) of 130 and extension (0) of 0 degrees.  Bilateral ankle ROM was plantar flexion (45) of 40 and dorsiflexion (20) of 5 degrees.  Bilateral lower extremity muscle strength and deep tendon reflexes (DTRs) were normal and symmetrical and there were no pathological reflexes.  The diagnosis listed bilateral tibial stress fractures.  The Compensation and Pension (C&P) exam recounted the history and interventions.  The CI complained of chronic lower extremity pain involving the thighs, shins, ankles, and feet.  He denied any specific history of trauma to his legs, ankles, Achilles tendons, or feet.  The CI reported less discomfort in his thighs, but his shins continued to bother him, especially with prolonged standing.  Pain was exacerbated by activity (prolonged standing, walking, and repetitive motion).  He denied leg weakness, loss of ROM, or significant changes in terms of strength, speed, or coordination.  The CI did not require any assistive device and was not taking NSAIDs.  The physical exam revealed a normal gait and normal appearing musculature with normal tone.  There was discomfort over the shins (R > L) and Achilles tenderness to pinch testing.  Bilateral ankle ROM was plantar flexion (45) of 40 and dorsiflexion (20) of 20 degrees.  Bilateral lower extremity muscle strength and DTRs were normal.  The diagnoses listed bilateral tibia stress reaction and mild bilateral Achilles tendonitis.

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each tibial stress fracture remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The Informal PEB rated the bilateral tibial stress fractures at 0% (VA code 5099-5003; rating by analogy-degenerative arthritis).  The PEB cited chronic lower leg pain over the tibias, insidious in onset, positive bone scan, normal X-rays, and rated for slight/intermittent pain.  The VA Rating Decision (VARD), citing the C&P exam 2 weeks after separation, rated the left tibial stress fracture at 10% (5262; tibia and fibula, impairment of) and the right tibial stress fracture at 10% (5262).  The VARD cited tibial stress reactions, Achilles tendonitis, malunion of the tibia and fibula, and slight disability.  The Board noted that there was no limitation of motion of the ankles or knees to support a compensable rating under 5271 (ankle, limited motion of), 5260 (leg, limitation of flexion of), or and 5261 (leg, limitation of extension of).  Members debated if 0% was warranted for the bilateral legs or if application of §4.40 (functional loss) or §4.59 (painful motion) justified a 10% ratings.  The Board carefully considered the option of rating both tibial stress fractures together, noting that the VA rated each leg separately.  The Board concluded that there was not a reasonable justification to support a finding of separately unfit for each of the CI’s legs.  Furthermore it was the combination of both legs which caused the CI to be unfit for his leg condition; and a bilateral rating of 10%, coded 5299-5262 is 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 tibial stress fracture condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the diffuse muscle and joint pains, mild intermittent leg pain, asthma, low TSH, and high blood pressure conditions 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.  

Contended Diffuse Muscle, Joint, and Mild Intermittent Leg Pain Condition.  The STR documents that the CI had a symptom complex predominantly involving multifocal limb muscle pain.  The bilateral leg pain was associated with transient, recurrent, sensory symptomatology in association with systemic fatigue.  The CI reported nonspecific, progressive, subjective complaints of the bilateral lower extremities.  These included muscle weakness, numbness, tingling, throbbing, and diffuse myalgias (muscle pain).  The CI complained of bilateral thigh, knee, and ankle throbbing pain.  There was intermittent shooting pain emanating from his distal thighs with radiation of pins and needles into the calves and feet.  The CI described the upper quadriceps pain “…as an instantaneous type pain which is very intense for a few seconds and then disappears totally.”  With the exception of mild and transient abnormalities, an extensive and comprehensive lab evaluation was unremarkable.  An electro-diagnostic study (electro-neuromyography) was normal.  A muscle biopsy showed minimal and nonspecific histologic (microscopic anatomical structure) changes.  A lower extremity MRI showed no evidence of myositis (muscle tissue inflammation and degeneration).  The impression, listed in a second opinion from a civilian neurologist, was symptoms of unclear etiology (cause or origin).  The physical exam, in the neurology consultation for MEB, documented normal heel walking, toe walking, and tandem gait.  There was normal muscle normal tone and bulk with no atrophy.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The diagnosis listed leg pain without explanation that is intermittent and mild.  The neurologist documented that the neurologic condition met retention criteria.  He opined that with regards to his neurologic complaints, the CI could perform his duties, should be returned to duty, and there were no geographic assignment considerations.  The physical exam, in the rheumatology consultation for MEB, documented full ROM at all joints and no evidence of synovitis (synovial membrane inflammation).  The abbreviated neurologic (motor) exam recorded normal strength in the proximal and distal lower extremity musculature.  The laboratory, pathology, and diagnostic imaging workup had not revealed evidence of a metabolic myopathy (skeletal muscle disease) or inflammatory myositis.  The rheumatologist found no evidence of an underlying systemic rheumatic illness or inflammatory myositis.  He stated the etiology for the CI's brief episodes of muscle region pain remain unexplained.  The diagnosis listed diffuse muscle and joint pains and the examiner documented that these complaints met retention criteria.  The shared history and exam findings from the NARSUM are listed above under the bilateral tibial stress fractures.  The diagnoses listed diffuse muscle and joint pains and leg pain without explanation that is intermittent and mild.  The diffuse muscle, joint, and mild intermittent leg pain was not profiled, not implicated in the commander’s statement, met retention by the MEB, and was considered to be not unfitting by the PEB.

Contended Asthma Condition.  The STR documents a history of childhood asthma.  A chest X-ray was unremarkable.  The CI underwent serial pulmonary function tests (PFTs).  In the pulmonary consultation for MEB, the CI reported a history of childhood asthma manifested by shortness of breath (dyspnea) and wheezing.  Symptoms resolved at 12 years of age and the CI was asymptomatic until approximately six months prior to the evaluation.  He complained of increased dyspnea with associated cough and wheezing.  Symptoms were relieved by albuterol, which the CI used approximately three times per week.  He denied nocturnal dyspnea, except when he developed a viral syndrome, and denied admission to a hospital because of dyspnea.  The CI reported his ability to perform his job was not limited by his shortness of breath.  Integrating the findings from the history, imaging studies, PFTs, and physical exam, the pulmonologist characterized the asthma as mild intermittent.  The pulmonologist documented that the asthma condition met retention criteria.  He opined that with regards to his asthma, it was well controlled on the albuterol inhaler as needed, it did not limit his ability to be deployed, he could be returned to duty, and no permanent profile was required.  The mild intermittent asthma was not profiled, not implicated in the commander’s statement, met retention by the MEB, and was considered to be not unfitting by the PEB.

Contended Low TSH Condition.  The STR documents an isolated lab value showing a slightly low TSH.  The endocrinology consultation for MEB recorded that the low TSH was probably secondary to the steroid (prednisone) the CI had taken previously for his asthma.  The endocrinologist documented that the low TSH condition met retention criteria.  He opined that with regards to his thyroid lab abnormality, the CI was without any symptoms of thyroid disease, there was no impact on his MOS duty performance, and he should be returned to duty.  The low TSH condition was not profiled, not implicated in the commander’s statement, met retention by the MEB, and was considered to be not unfitting by the PEB.

Contended High Blood Pressure Condition.  The STR documents a history of high blood pressure (hypertension) treated with a single, low dose, antihypertensive agent (Lisinopril 20 mg daily).  His treatment was characterized as “well controlled with his current medications.  The high blood pressure condition was not profiled, not implicated in the commander’s statement, met retention by the MEB, and was considered to be not unfitting by the PEB.

All contended conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  The Board determined that the preponderance of evidence indicated that these conditions were not unfitting for continued military service.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the diffuse muscle and joint pains, mild intermittent leg pain, asthma, low TSH, and high blood pressure conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating the bilateral tibial stress fracture condition was operant in this case and the condition was adjudicated independently of that policy/instruction by this Board.  In the matter of the bilateral tibial stress fracture condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the contended diffuse muscle and joint pains, mild intermittent leg pain, asthma, low TSH, and high blood pressure 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Lower Leg Pain	5299-5262	10%	
COMBINED	10%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140627, 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 XXX, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20160004076 (PD201403160)

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: